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GUIDELINES ON

MEDICAL SURVEILLANCE
Under the Occupational Safety and Health
(Use and Standard of Exposure of
Chemicals Hazardous to Health)
Regulations, 2000
P.U.(A)131

DEPARTMENT OF OCCUPATIONAL SAFETY AND HEALTH


MINISTRY OF HUMAN RESOURCES
MALAYSIA
2001
JKKP:GP(1)/4/2001
ISBN 983-2104-16-6

CONTENTS
Page
Preface

Acknowledgements

ii

Definitions

Introduction

Legal Provision

Objectives

Components of Medical Surveillance

Duties of Occupational Health Doctor

Duties of Employer

Duties of Employee

SCHEDULE II
(Subregulation 27(3))
(Chemicals for which medical surveillance is appropriate)
1. 4-Aminodiphenyl

6 - 7

2. Arsenic And Any Of It Compound

8 - 14

3. Asbestos (All Forms Except Crocidolite)

15 - 17

4. Auramine, Magenta

18 - 19

5. Benzidine

20 - 22

6. Beryllium

23 - 25

7. Cadmium And Any Of Its Compound

26 - 30

8. Carbon Disulphide

31 - 34

9. Disulphur dichloride

35 - 36

10. Benzene including benzol

37 - 40

11. Carbon Tetrachloride

41 - 43

12. Trichloroethylene

44 - 47

13. n Hexane

48 - 50

14. bis (Chloromethyl) ether

51 - 52

15. Chromic Acid

53 - 55

16. Chromium, metal and inorganic compounds,


e.g. Water-Soluble Cr VI compounds, Insoluble Cr VI compounds

53 - 55

17. Free crystalline silica

56 - 58

18. Isocyanates

59 - 61

19. Lead (including organic lead compounds)

62 - 68

20. Manganese

69 - 71

21. Mercury

72 - 75

22. Mineral oil including paraffin

76 - 77

23. b-Naphthylamine

78 - 79

24. 1-Naphthylamine and its salts

80 - 81

25. Orthotolidine and its salts

82 - 83

26. Dianisidine and its salts

84 - 85

27. Dichlorobenzidine and its salts

86 - 87

28. 4-Nitrodiphenyl

88 - 89

29. Nitro or amino derivatives of phenol and of benzene


or its homologues

90 -100

30. Nitrous fumes. Chromate or dichromate of potassium,


sodium ammonium or zinc

101 - 103

31. Pesticides (organophosphates)

104 - 107

32. Pitch

108 - 110

33. Tar, bitumen and creosote

108 - 110

34. Vinyl chloride monomer (VCM)

111 - 114

35. Nickel sulfide roasting, fume and dust as nickel

115 - 116

PREFACE

These guidelines may be cited as the Guidelines on Medical Surveillance.


The purpose of these guidelines is to guide, clarify and elaborate on the content and
frequency of medical surveillance to be conducted by the Occupational Health Doctor
(OHD) in complying with the requirements of Regulations 27(2), Occupational Safety
and Health (Use and Standard of Exposure of Chemicals Hazardous to Health)
Regulations 2000.
Employers are also encouraged to read these guidelines in conjunction with the
Occupational Safety and Health (Use and Standard of Exposure of Chemicals
Hazardous to Health) Regulations 2000 so that it will help them in fulfilling with the
requirements of Regulations 27(1)
for Health Surveillance Programme
in a
comprehensive and integrated approach.
Employers and employees must understand the rationale for and the importance of
occupational health surveillance programme as this will improve their cooperation with
the OHD in ensuring success of conducting the programme.
These guidelines will be reviewed from time to time. Assessors, hygiene technicians,
occupational health doctors, employers, employees and others concerned are invited to
gives their comments in writing or e-mail to the Department of Occupational Safety and
Health, so that that these guidelines will be continuously improved thus making the
maximum contribution to the prevention and control of occupational disease and
poisoning thereby increasing organisational productivity and health of the working
population.

Director General
Department Occupational Safety and Health
Malaysia
October 2001

ACKNOWLEDGEMENT
The Department of Occupational Safety and Health, Malaysia wishes to thank and
acknowledge the following individuals and their respective organisations for their contributions
towards the preparation of this guidelines:
NAME
1.
2.
3.

Ir. Haji Abu Bakar Che Man


Ir. Zainuddin Bin Abdullah
Dr. Zainul Abidin bin Md Hussain

4.
5.
6.

Dr. Abed Onn


Dr. Sulaiman Mohd.Nawawi
Prof. Dr. K G Rampal

7.

Prof. Madya Dr. Noor Hashim Ismail

8.

Dr. Roslina Ali

9.

Dr. Sirajuddin Hj. Hashim

INSTITUTION

11. Dr. Mohd Yusof Adon

Director General, DOSH


Deputy Director General, DOSH
Deputy Director, Occupational Health Unit ,
DOSH Headquarters
Executive Director, NIOSH
Director, Occupational Health Division, NIOSH
Department of Community Health,
Medical Faculty, UKM, KL
Department of Community Health,
Medical Faculty, UKM, KL
Principal Asst. Director, Occupational Health Unit,
Disease Control Division, Ministry of Health
Assistant Director, Occupational Health Unit,
Disease Control Division, Ministry of Health
Assistant Director, Occupational Health Unit,
Disease Control Division, Ministry of Health
Health Department, Selangor

12. Dr. Abu Hassan Samad

Medical Advisor, Esso, KL

13. Dr. M. Sharkawi Jaya

Group Occupational Health Advisor,


Petronas, KL

14. Dr. Abdul Rahim Rahman Hamzah

Head, Occupational & Environmental Health Unit,


Dept. of Social & Preventive Medicine, UM

15. Dr. Mohd Hatta Hj Usul


16. Dr. Mustafa Ali
17. Dr Amar Singh

Health Advisor, Petronas Cari Gali Sdn Bhd


Pharmacology Department, University Malaya
Medical Director, SHELL

18.
19.
20.
21.

Dr. Zakira Taib


Puan Nursiah Md Tajol Arus
Dr. Jagdev Singh
Dr. Ling Kin Hong

22.
23.
24.
25.
26.
27.
28.
29.

Pn. Mauziah Abdul Rahman


En. Ibrahim Abdul Rahman
Pn. Zaiton Sharif
Pn. Habibah Supoh
Cik Zamrudah Yeop
En. Zahari Idi
Cik Zalinah Salikin
En.Chee Hood Sin

Health Office, District of Gombak


Pesticide Control Division, Ministry of Agriculture
Malaysian Society of Occupational Safety & Health
Occupational & Environmental Health Unit,
Dept. of Social & Preventive Medicine, UM
Deputy Director, DOSH Headquarters
Deputy Director, DOSH Headquarters
Assistant Director, DOSH Headquarters
Assistant Director, DOSH Headquarters
Assistant Director, DOSH Headquarters
Occup. Safety & Health Officer, DOSH, Pulau Pinang
Occup. Safety & Health Officer, DOSH Headquarters
Occup. Safety & Health Officer, DOSH Headquarters

10. Dr. Fatanah bt Ismail

For further information, please contact:


Department of Occupational Safety and Health
Level 2, 3 & 4 Block D3
Pusat Pentadbiran Kerajaan Persekutuan
62506 Wilayah Persekutuan Putrajaya
Tel: 03-88865200; Fax: 03-88892339
e-mail: jkkp@dosh.gov.my

DEFINITIONS
Assessor means an employee or any other person appointed by the employer and registered
with the Director General of DOSH to carry out assessments of risks to health.
Biological Effect Monitoring means the sub-clinical biological effect caused by the hazards.
Biological Exposure Indices (BEIs) are reference values intended as guidelines for the
evaluation of potential health hazards in the practice of occupational hygiene. BEIs represent
the level of determinants which are most likely to be observed in specimens collected from a
healthy worker who has been exposed to chemicals to the same extent as workers with
inhalation exposure at the TLV. These values are developed by ACGIH as a guide for biological
monitoring of chemicals.
Biological monitoring means the measurement and assessment of agents or their metabolites
either in tissues, secreta, excreta, expired air or any combination of these to evaluate exposure
and health risk compared to an appropriate reference.
Chemicals means chemical elements or compounds or mixtures thereof, whether natural or
synthetic, but does not include micro-organisms.
Chemicals hazardous to health means any chemical which :
a) is listed in Schedule I or II;
b) possess any of the properties categorised in Part B of Schedule I of the
Occupational
Safety and Health (Classification, Packaging and Labelling of Hazardous
Chemicals)
Regulations 1997;
c) comes within the definition of pesticide under the Pesticides Act 1974;
d) is listed in the First Schedule of the Environmental Quality (Schedule Wastes)
Regulations 1989.
Health surveillance means any examination and investigations which may be necessary to
detect exposure levels and early biological effects and responses, and includes biological
monitoring, biological effect monitoring, medical surveillance, enquires about symptoms of
occupational poisoning or occupational disease and review of records and occupational history.
Hygiene technician means an employee or any other person appointed by the employer and
registered with the DG (DOSH) to carry out any inspection, examination or test on engineering
control equipment installed in a place of work or to carry out chemical exposure monitoring.
Medical surveillance means the monitoring of a person for the purpose of identifying changes
in health status due to occupational exposure to chemicals hazardous to health.
Occupational Health Doctor means a medical practitioner registered with the DG (DOSH) to
conduct medical surveillance programme of employees.
Occupational Medical Surveillance Records means forms specified in this guidelines for the
purpose of keeping of medical records.
Permissible Exposure Limit (PEL) means a ceiling limit or an eight-hour time-weighted
average airborne concentration or the maximum exposure limit.
Supplier means a person who supplies chemicals and includes a formulator, a manufacturer
and importer or a distributor.
Time-weighted average (TWA) in relation to airborne concentration means an average
airborne concentration over a specified period of time.
Use means production, processing, handling, storage, transport, disposal and treatment.

1.0

INTRODUCTION

Malaysia is taking great steps to be an industrialised nation by the year 2020. This will entail
heavy and extensive use of chemicals.
The Occupational Safety and Health (Classification, Packaging and Labeling) Regulations 1997
and the Manual of Chemical Health Risk Assessment 2000 helps employers to assess whether
there is any significant exposure of the chemicals to the worker and further medical surveillance
is necessary.
The Occupational Safety and Health (Use and Standards of Exposure of Chemicals Hazardous
to Health) Regulations 2000 is another attempt to further enhance the safe and healthy use of
chemicals.
Under this Regulations health surveillance is necessary for chemicals hazardous to health as
stipulated in the regulations. Medical surveillance carried out under the USECHH Regulations
must be conducted by an Occupational Health Doctor (OHD).
2.0

LEGAL PROVISION

OCCUPATIONAL SAFETY AND HEALTH (USE AND STANDARD OF EXPOSURE OF


CHEMICALS HAZARDOUS TO HEALTH) REGULATIONS 2000
PART IX
HEALTH SURVEILLANCE
Health surveillance programme
Regulation 27
(1) Where an assessment indicates that health surveillance is necessary for the protection of
the health of employees exposed or likely to be exposed to chemicals hazardous to health, the
employer shall carry out a health surveillance programme.
(2) If an employee is exposed or likely to be exposed to chemicals hazardous to health
listed in Schedule II, and is engaged in a process specified therein, the health surveillance
required under sub-regulation (1) shall include medical surveillance conducted by an
occupational health doctor at intervals of not more than twelve months or at such shorter
intervals as determined by the occupational health doctor or an occupational safety and health
officer who is also a medical practitioner.
(3) The employer shall ensure that the health surveillance record or a copy there of is
maintained in good order and condition and kept for a period of thirty years from the date of the
last entry made in it.
(4) The employer shall make available upon request all records required to be maintained
under sub-regulation (3) to the DG (DOSH) for examination and inspection.
(5) The employer shall, after a reasonable notice being given, allow any of his employees
access to the health surveillance record which relates to the employee.

PART X
MEDICAL REMOVAL PROTECTION
Regulation 28
(1) The employer shall not permit an employee to be engaged in and shall remove him from
any work that exposes or likely to expose him to chemicals hazardous to health on each
occasion that the medical finding, determination or opinion expressed by an occupational safety
and health officer who is also a medical practitioner or by an occupational health doctor shows
that the employee has a detected medical condition which places him at increased risk of
material impairment to health from exposure to chemicals hazardous to health.
(2) The employer, after being notified by an occupational safety and health officer who is also
a medical practitioner or an occupational health doctor of the fact, shall not permit a pregnant
employee or breast-feeding employee to be engaged in, and shall remove the employee from
work which may expose or is likely to expose the employee to chemicals hazardous to health.
(3)

The employer shall return an employee to his former job -

(a) for an employee removed in accordance with sub-regulation (1), when a subsequent
medical determination results in a medical finding, determination or opinion which shows
that the employee no longer has the detected medical condition; or
(b) for an employee removed in accordance with sub-regulation (2), at the appropriate time
where the employee is no longer pregnant or breast-feeding a child.
(4) For the purposes of this regulation, medical practitioner means a medical practitioner
registered under the Medical Act 1971 [Act 50].
3.0

THE OBJECTIVES OF THE GUIDELINES ON MEDICAL SURVEILLANCE

The objective of this GUIDELINES ON MEDICAL SURVEILLANCE is to help occupational


health doctors (OHD), registered with DOSH to implement the guidelines according to
Occupational Safety and Health (Use and Standard of Exposure of Chemicals Hazardous to
Health) Regulations 2000.
4.0

COMPONENTS OF MEDICAL SURVEILLANCE

The components of Medical Surveillance Programme include :


Pre-employment and pre-placement medical examination.
Biological monitoring and biological effect monitoring.
Health effects monitoring.
Investigation of occupational disease and poisoning including workplace
inspections.
Notification of occupational disease and poisoning.
Assist in disability assessment.
Return to work examination after medical removal protection.
Record keeping and monitoring.

5.0

DUTIES OF OCCUPATIONAL HEALTH DOCTOR (OHD)

(1)

Conduct the pre-employment and pre-placement medical examination (baseline medical


data) of employees to assess fitness for work, taking into consideration the hazards and
risk assessment in the workplace. The use of Occupational Medical Surveillance
Programme Record Book and Employee Record Book is suggested.

(2)

Determination of the ability to work while wearing the Personal Protective Equipment.

(3)

Maintain the medical records of employees during the course of employment (periodic)
and post termination.

(4)

Documentation of employee exposure to hazards at workplace.

(5)

Interpret and explain the results of investigations to the EMPLOYEE AND EMPLOYER
and specify what further follow up action is necessary.

(6)

Analysis of Occupational Diseases & Poisoning and co-relate with Chemical Health Risk
Assessment.

(7)

Investigation of the cause of the Occupational Disease / Poisoning. Visit work place and
recommend remedial actions. For medical removal protection use the appropriate forms.

(8)

Notification of Occupational Diseases & Poisoning to DOSH and employer.

(9)

Assist in Implementation of Occupational Health Programme in the workplace.

(10)

Assist in the management of Occupational Diseases & Poisoning including removal from
work, treatment, rehabilitation, disability assessment, return to work and / or
compensation.

(11)

Reinforce the value of education/ training in Occupational Health to both employer and
employee.

(12)

Assist in Audit / Evaluation of Occupational Health Programme in the workplace.

6.0

DUTIES OF EMPLOYER

(1)

Carry out health surveillance programme as required by the assessment report under
USECHH Regulations.

(2)

Health surveillance programme shall be conducted during the working hours and the
costs shall be borne by the employer.

(3)

Appoint an Occupational Health Doctor, (OHD) to


surveillance programme.

(4)

Allow and assist the OHD to visit the workplace to investigate and manage occupational
disease and poisoning including access to relevant monitoring and other health related
data.

(5)

Co-operate with the OHD in medical removal protection of the worker.

(6)

During the period of medical removal the worker may be allowed to do other work that
will not expose him to the hazardous chemical.

conduct occupational medical

(7)

Notify occupational disease and poisoning to DOSH .

(8)

Notify the workers concerned regarding monitoring of exposure levels of chemicals


hazardous to health including occupational disease and poisoning.

(9)

Allow the employee access to occupational medical surveillance records.

(10)

Ensure the workplace hygiene is improved, is safe and healthy and does not place the
worker at increased risk of material impairment to health from exposure to chemical
hazardous to health. before allowing the worker to work in the same place so as to
ensure the disease or poisoning does not reoccur.

(11)

Record Keeping of diseases and accidents.

(12)

Provide Employee Medical Book.

7.

DUTIES OF EMPLOYEE

(1)

Undergo training on importance of preventing occupational poisoning and disease.

(2)

Report early symptoms and signs of disease ( including self examination) to the OHD
and management.

(3)

Comply and co-operate in the Occupational Medical Surveillance Programme, as


required under USECHH.

(4)

To take proper care of the Employee Record Book and to present it to OHD for
Occupational Medical Surveillance record purposes.

Guidelines On Medical Surveillance

Liver, Kidney, CNS, Nerve damage.


1.

4- AMINODIPHENYL

4.0 MEDICAL SURVEILLANCE


PROGRAMME

1.0 SYNONYMS: p-aminodiphenyl,

Indicated for exposure to 4-Aminodiphenyl

4- aminobiphenyl, biphenylamine,

or possibility of excessive absorption.

p-phenylaniline and xenylamine.


It is an aromatic amine.

4.1 PRE-PLACEMENT

PEL 8 hr TWA : 0

MEDICAL

EXAMINATIONS

Physicochemical properties

Clinical examination and baseline data with

Colourless to straw coloured liquids and

particular attention to:

crystals.

Kidneys- Urine cytology

On combustion, forms toxic gases.

Neurological and

Respiratory system

Route of Absorption
Inhalation,
2.0

Dermal (skin)

OCCUPATIONS AT RISK OF

EXPOSURE
Organic

chemical

including

solvents,

synthesis
perfume

4.2 PERIODIC

Annually but much more frequently if


exposure is high.

manufacture
Dye

intermediate,

4- aminodiphenyl exceed PEL)

rubber industry

3.O

TOXIC EFFECTS

3.1

ACUTE EFFECTS

5.0

All cases of definite or suspected


poisoning / disease and excessive

Anorexia, vomiting
Irritation of eye, skin & respiratory tract
Burning urinary sensation due to acute
haemorrhagic cystitis

tumours.

carcinogen

absorption.
All cases of Medical Removal Protection
(MRP), cases of
poisoning

definite or suspected

disease

and

excessive

absorption must be notified to the Director


General (DG), Department of Occupational

CHRONIC EFFECTS

Bladder

INDICATIONS FOR MEDICAL


REMOVAL PROTECTION

Headache, dizziness, lethargy, ataxia

3. 2

Urine cytology

Methaemoglobinemia ( if levels of

photography,

Used as heat transfer agents.

MEDICAL

EXAMINATIONS

Confirmed

(IARC 1).

Safety and Health (DOSH).

A1

(ACGIH)

Department of Occupational Safety and Health (DOSH) Malaysia

Guidelines On Medical Surveillance

6.0 FOLLOW-UP ACTIONS

advisable for the worker not to


smoke.

6.1

ABNORMAL RESULTS

If symptoms & signs including abnormal

Aminobiphenyl is prohibited in the use

urine cytology persist, a repeat test must

for

be done immediately.

purposes except for research &

Refer to urologist for further examination.

analytical purposes in Malaysia.

6.2

MEDICALLY REMOVED WORKER


& RETURN TO WORK
All medically removed workers should

1.

Factories

abnormal cytology and biochemical


Recommend the worker for return to
work when the workplace hygiene is

2.

material impairment to health from

3.

toxicology, Industrial Health Services


Barberton, Ohio; 1987:155-6.
4.

Aromatic Hydrocarbon, in International


Labour

5.

removed from exposure and referred for


hospital treatment.

Office:

Encyclopaedia

Health

and

of

Safety,

in

work-process

hygiene,

&

adequate

ventilation and appropriate signage.


protective

equipment,

Chemical goggles.
smoke

Aminobiphenyl,

as

Rom

MN

Environmental

Occupational

Medicine

Little

&

Brown

nd

Co.Boston,

&

Edition
1992:

882,1213, 1379.

PREVENTIVE MEASURES

Cigarette

Plunkett ER Handbook of Industrial

Geneva, 4th edition, 1998:104.273.

All cases of poisoning must be immediately

Personal

Olson KR. Poisoning & Drug overdose,

Occupational

6.3 TREATMENT

workplace

Community,

Int. (UK) Ltd., London; 1999: 438t.

exposure to 4-Aminodiphenyl.

Improvement

of

A Lang Clinical manual: Prentice-Hall

safe and healthy and does not place


the worker at increased risk of

Dept

Examinations)

National University of Singapore 1997.

results have recovered.

7.0

(Medical

Occupational and Family Medicine,

The worker should not return to work


symptoms,

all

Phoon WH, Magdalene Chan, Ho SF,

Regulations

and

for

For Designated Factory Doctors-The

month.

signs

use

Dept of Industrial Health Guidelines

relevant biochemical tests within one

the

&

8.0 REFERENCES

have repeat urine investigations and

until

manufacture

contains
such

it

6.

OSHA

Reg.

(Stds

-29

CFR)

Aminodiphenyl 1926-1111.
7.

www.osha.slc.gov

8.

Information

on

the

Prohibition

of

Substances form Certain Purposes.


DOSH, 1999:2.

is

Department of Occupational Safety and Health (DOSH) Malaysia

Guidelines On Medical Surveillance

ethylated to form dimethylarsenic acid and


2.

ARSENIC AND ANY OF ITS

methylarsenic

COMPOUNDS
acid. Once absorbed, arsenicals disrupt
SYNONYMS: Arsenic Trichloride,

1.0

enzymatic

reactions

vital

to

cellular

Arsenic Trioxide, White Arsenic

metabolism by interacting with sulfhydryl

PEL 8 hr TWA:

groups (trivalent Arsenic or substituting for

Arsenic

phosphate (pentavalent arsenic).

(elemental & inorganic

0.01 mg/m3)

Arsine

0.05 ppm

Arsine-ILH

Excretion
Most of the absorbed arsenic is excreted in

(Immediate Lethal to Health)

150 ppm

the urine, with small amounts being


excreted in the faeces. The maximum

Physicochemical properties

excretion occurs in the first 6 hours, with

Elemental arsenic is silvery lustrous

about 25% being excreted in 24 hours and

metalloid. Arsenic compounds arsenic (III)

about 75% within 7 days of exposure.

oxide, arsenic (V) oxide, the acids formed

Half-life of inorganic arsenic is hour and

from these oxides and their salts and

has ethylated metabolites 5-20 hours.

organic compounds are more commonly


encountered than arsenic metal.

TOXIC EFFECTS OF ARSENIC AND ANY

Trivalent arsenic is 2-10 times more

OF ITS COMPOUNDS

toxic than the pentavalant form.

A: INORGANIC ARSENIC
B: RGANIC ARSENIC

Route of Absorption

C: ARSINE (AsH3)

Inhalation
Arsenic particles may be deposited in the
upper respiratory tract, cleared from upper
respiratory

tract

and

swallowed

and

2.0 OCCUPATIONS INVOLVING RISK


OF EXPOSURE TO

absorbed from the gastrointestinal tract.

A: INORGANIC & B: ORGANIC

Ingestion

ARSENIC

Skin absorption is from open abrasions.


Arsenic acids may be absorbed through
intact skin.

Trivalent arsenic may be oxidized in the


body to the heptavalent state. The opposite
take

(weed killers, fungicides, wood


preservatives) in tanning, wood

Bio-transformation

can

Manufacture and use of pesticides

place. Inorganic arsenic is

preservation, horticulture
Manufacture of semiconductors
Gallium arsenide substrate
production and wafer processing

Department of Occupational Safety and Health (DOSH) Malaysia

Guidelines On Medical Surveillance

Cleaning and maintenance of iron

If inhaled arsenic dust and fumes cause

implant machines

irritation,

Handling of iron source

dyspnea, laryngitis, pharyngitis may occur.

Manufacture of alloy (with copper

Ingestion causes vomiting, dysphagia,

or lead) & glass

diarrhea, abdominal pain, dehydration and

Smelting of arsenical (especially

shock.

non-ferrous) ores.

3.2 CHRONIC EFFECT OF A:

rhinitis,

cough,

chest

pain,

INORGANIC ARSENIC

Dust generated during grinding,


screening, transfer and

Increased

maintenance work on furnaces,


flues and filters

pigmentation,

(after

Manufacture and use of organic


3

arsenical compounds e.g.


arsphenamine, neoarsphenamine,

Skin

sulpharsphenamine and

-7

years),

desquamation,
herpetic-like lesions

tryparsamide, veterinary
pharmaceutical products

about

Pigment manufacture and use


Manufacture and use of anti-

the

mouth,

hyperkeratosis

fouling paints.

(especially

Arsenic waste disposal.

and

of

palms

soles),

skin

3.0 TOXIC EFFECTS OF A: INORGANIC


cancer.

ARSENIC

Mees line (2-3 weeks


3.1 ACUTE EFFECT OF A: INORGANIC
Nails

ARSENIC
Acute poisoning is rare and is usually

Hair loss.

accidental. If ingested, symptoms of throat

Perforation

constriction, dysphagia, epigastric pain and


vomiting and watery diarrhea develop
within 1/2 to 4 hours. Fatal dose of
ingested elemental arsenic is 70-180 mg. If
not

fatal,

exfoliative

dermatitis

peripheral neuritis may develop.

and

post ingestion).

of

nasal

Respira

septum,

chronic

bronchitis,

basilar

tory
tract

fibrosis of lung.
Lung cancer.
Fatty infiltration.

Department of Occupational Safety and Health (DOSH) Malaysia

Guidelines On Medical Surveillance

Liver

Liver cirrhosis,

3.3 OTHER CONDITIONS A:


INORGANIC ARSENIC

chronic hepatitis.

Encephalopathy,

presents

Peripheral neuritis -

system

axonal

degeneration,

of

lungs

and

with

pigmentation,

malignant growths (IARC 1)

coma,

Nervous

(loss

skin,

keratosis and single or multiple

tremor.

initially

of

ethmoids reported. Skin cancer

convulsions,
hyperpyexia,

Cancer

Basal or squamous cell type

Genotoxic: chromosomal
aberrations in human
lymphocytes

Note:

Some

inorganic

arsenic

compounds (e.g. arsenic acid,

sensory

arsenic

sensation),

trichloride)

can

be

absorbed through intact skin.


Inorganic arsenicals are generally

later motor weakness.

more
Normochromic anaemia,

toxic

than

organic

arsenicals.

Haemato

neutropenia.

Thrombocytopenia,

PROGRAMME FOR ARSENIC & ITS

Poietic

aplastic anaemia,

COMPOUNDS

System

RBC

4.0 MEDICAL SURVEILLANCE

basophilic

Dyspahgia,

intesti

erosion,

nal

its compounds > 50% PEL or possibility of


excessive absorption.

stripling.
Gastro-

Any occupational exposure to arsenic and

mucosal
abdominal

4.1 PRE-PLACEMENT MEDICAL


EXAMINATIONS FOR A:
INORGANIC ARSENIC
Clinical examination & baseline data with

pain

particular emphasis on the:


Tubular
Kidney

&

glomerular

damage.

Nervous system

Liver, liver function tests


(Serum bilirubin, alkaline

Oliguria, uremia.

phosphatase, alanine and

Department of Occupational Safety and Health (DOSH) Malaysia

10

Guidelines On Medical Surveillance

aspartate transaminases and

Source: TLVs & BEIs ACGIH, 2000.

gamma-glutamyl transpeptidase)

As the half-life is short; therefore Blood

Skin

As

Nasal septum, lungs and

Urinalysis is by far the most reliable


procedure for monitoring employees

lymph nodes.

is less useful than urine levels.

exposed to arsenic. Unexposed

History of smoking,
medicines taken, alcohol

individuals normally show levels above

consumption, previous job.

0.05 mg/L.

4.2 PERIODIC MEDICAL EXAMINATION

Estimation of urinary
arsenic content in an early

A: INORGANIC ARSENIC

morning urine specimen (with

Done annually. Detect early skin

creatinine correction). Ensure

changes, (hyperpigmentation and

that worker avoids seafood for

thickening).
Regular self-inspection of skin by

three days prior to urine

workers is appropriate.

collection.
Fish and shellfish contain very large
4.3

amounts of organically bound

WHERE INDICATED THE

arsenic and these are readily

FOLLOWING TESTS MAY BE

absorbed from the GIT and quickly

DONE FOR INORGANIC ARSENIC:


Estimation of inorganic arsenic,

excreted in the urine.

Full-sized chest x-ray examination

urinary monomethylarsenic acid

(at pre-employment examination

(MMA) and dimethylarsenic acid

only).

(DMA) in an early morning urine

BIOLOGICAL EXPOSURE
DETERMINANTS
Determinants

Sampling

BEI

Time
Arsenic

specimen
Complete blood count including
differential count
Sputum cytology estimation
Kidney function tests.

and

soluble

5.0 INDICATIONS FOR MEDICAL

compounds
including

End of work

arsine

week

(Inorganic
arsenic

plus

REMOVAL PROTECTION
35g/L

A: INORGANIC ARSENIC
All cases of definite or suspected

methylated

arsenic poisoning and excessive

metabolites in

absorption.

urine)

Department of Occupational Safety and Health (DOSH) Malaysia

11

Guidelines On Medical Surveillance

Cases with urine arsenic levels of


more than 300 g/ L in 2
successive examinations.

3.0 TOXIC EFFECTS OF ARSINE

intravascular

Symptoms develop within hours of


exposure

women
Workers with persistent liver

massive

haemolysis

All cases with evidence of cancer.


All breast-feeding & pregnant

Causes

Triad of haemoglobinuria (port-

abnormalities (one or more

wine urine), jaundice (coppery-

abnormal result in the liver function

bronze hue) and abdominal pain.

on at least 2 occasions, the test

and ECG changes

being carried out preferably not


more than one month apart).

Associated shivering, severe thirst

Death is due to acute renal failure.


(Haemolyses & haemoglobinuria)

B: ORGANIC ARSENIC

4.1 PRE-PLACEMENT MEDICAL


2.0 TOXIC EFFECTS OF ORGANIC
ARSENIC
Skin and mucous membrane irritation.

EXAMINATIONS FOR C: ARSINE


Clinical examination & baseline data with
particular emphasis on the:

bilirubin, alkaline phosphatase,

C: ARSINE

serum transaminases e.g. SGOT,

Most toxic form of arsenic


Has poor olfactory warning property. Non-

SGPT, gamma-glutamyl
transpeptidase)

irritating, colorless, neutral gas, slightly


soluble in water.

Liver, liver function tests (Serum

Renal -Urine dipstick examination


for protein and blood.

2.0 OCCUPATIONS INVOLVING RISK


OF EXPOSURE TO ARSINE

Hematological
Hemoglobin

systems

estimation

and

Accidental exposures during tin

peripheral blood film examination

refining, cleaning of tanks

to look for basophilic stippling.

containing acid sludge, smelting


and chemical industries
Used in organic synthesis
Is a byproduct of metal smelting
Manufacture of solid state

To exclude workers with cardiac or renal


disease and those with hypersensitivity to
hemolytic agents.
Estimation

of

urinary

arsenic

semiconductors;

content in an early morning urine

Accidental leakage, explosion or

specimen

equipment, malfunction during use

correction). Ensure that the worker

as a dopant gas.

avoids seafood for 3 days prior to

Department of Occupational Safety and Health (DOSH) Malaysia

(with

creatinine

12

Guidelines On Medical Surveillance

4.2

urine collection as it may contain

All cases recommended for suspension

arsenic.

and suspected cases of arsenic/arsine


poisoning / excessive absorption must be

PERIODIC MEDICAL

notified to the DG (DOSH).

EXAMINATION C: ARSINE
Annually as for pre-employment.

6.0 FOLLOW-UP ACTIONS

Renal function tests.


5.0 INDICATIONS FOR MEDICAL

6.1 ABNORMAL RESULTS ARSENIC

REMOVAL PROTECTION C:
ARSINE

If the urine arsenic level exceeds

All cases of definite or suspected

300 g/ L, a repeat test must be

arsine poisoning and excessive

done immediately.

absorption.

Cases

All cases with urine arsenic levels

function

of more than 300 g/L in 2

investigated to exclude effects

successive examinations.

due to arsenic.

All cases with anaemia,

Cases with anemia, proteinuria or

proteinuria or haematuria.

haematuria

with

abnormal

tests

should

should

investigated to exclude

(Note: Each laboratory has its


own

'normal

range'

for

haemoglobin. The lower limit of


this range, subject to a margin of
error of up to 5%, depending on
the laboratory, may be taken as
the level for the diagnosis of
anemia).

be

be
effects

due to arsine.
6.2 MEDICALLY REMOVED WORKER &
RETURN TO WORK
All suspended cases should have
repeat
examinations

urine

arsenic

at

3-monthly

intervals and should not return to


arsenic work until the urinary

All pregnant and breast-feeding

arsenic level falls below 300

women where exposure is 50% of

g/litre

PEL.

liver

Workers

function

symptoms

have

disappeared
with

abnormalities
abnormal

and

persistent
(one

result
test

on

or

in
at

the

liver
more
liver

least

occasions, the tests being carried

Cases with definite evidence of


cancer should preferably not
continue with arsenic or arsine
work.

out preferably not more than one


month apart).
Department of Occupational Safety and Health (DOSH) Malaysia

13

Guidelines On Medical Surveillance

The worker may return to work

Regulations

with arsenic when the liver

Occupational and Family Medicine,

function results return to normal

National University of Singapore 1997.

Dept

of

Community,

and he is clinically asymptomatic.


2.

National

Institute

for

Occupational

Recommend the worker for return

Safety and Health: Criteria for a

to work when the

Recommended

workplace

Standard.

hygiene is safe and healthy and

Occupational exposure to inorganic

does not place the worker at

arsenic

increased

risk

impairment

of

to

(new

criteria

-1975).

US

material

Department of Health, Education and

from

Welfare, USA. (HEW Publication No

health

exposure to arsenic.

(NIOSH) 75 -149), 1975.

6.3 TREATMENT

3.

International

Labour

Office:

Encyclopaedia of Occupational Health

First Aid: Evaluate & support

and Safety, Geneva, 4th edition, 1998.

(ABCs Airway breathing &


circulation) Administer charcoal if
available.

4.

Employment Medical Advisory Service:


Occasional

Refer for hospital treatment. BAL

Paper

1,

Biochemical

Criteria in certain biological media for

is the antidote for inorganic

selected toxic substances, Dept of

arsenic including haemolysis.

Employment, UK, 1974.

Other chelating agents are not


effective for arsenic poisoning.

5.

Occupational
Authority:

Safety

Medical

&

Health

Surveillance

Guidelines 1910.1018 App C, 1989.


7.0

PREVENTIVE MEASURES
6.

Improvement in work process

Health

Organisation:

Early

Improvement work-place hygiene

detection of occupational diseases.

Use of approved Personal

Chapter 12, Diseases Caused by

Protective Equipment

arsenic and its toxic compounds, 1986:

Appropriate signage.

74-8.
7.

8.0 REFERENCES
1.

World

Phoon WH, Magdalene Chan, Dept of


Industrial
Designated
Factories

Health

Guidelines

Factory
(Medical

For

Doctors-The

Donald S Herip: Recommendations for


the investigation of abnormal hepatic
function in asymptomatic workers. Am
J Ind Medicine, 1992; 21: 331-9.

Examinations)

Department of Occupational Safety and Health (DOSH) Malaysia

14

Guidelines On Medical Surveillance

8.

American

Conference

Governmental

Industrial

of

Hygienist:

Documentation of the Threshold Limit


Values

and

Biological

Exposures

Indices, Cincinnati 1999.


9.

Control of Substances Hazardous to


Health
Regulation

(COSHH)
11-Health

Regulations:
Surveillance-

Arsenic in The Health and Safety


Factbook Health & safety Executive,
Professional Publishing Ltd London,
1989:1/5.

3.

ASBESTOS

1.0 PHYSICOCHEMICAL PROPERTIES


It is a term form for a group of naturally
occurring fibrous mineral silicates. There
are 2 groups and 6 mineral types:

Department of Occupational Safety and Health (DOSH) Malaysia

15

Guidelines On Medical Surveillance

Sepentine
group

Amphibole group
crocidolite, amosite,

Chrysotile

anthophylite, tremolite,
actinolite.

PEL 8hr TWA: 0.1 f /ml.


Route of entry

Inhalation
2.0

3.0 TOXIC EFFECTS


Signs of toxicity are usually delayed at
least 15-30 years.
Pleural plaques
Mesothelioma (cancer of the pleural
or mediastinal)

Benign pleural effusion

Asbestosis-fibrosis with shortness of


breath

OCCUPATIONS AT RISK OF
EXPOSURE

Asbestos milling and processing


Manufacture and use of asbestos-

and cough

Chronic bronchitis
Bronchogenic
smoking is

Cancer

(cigarette

an important synergistic

factor and the risk may be increased

cement products e g. roofing sheets,

by

wall boards, fireproof cloth, brakes

compared to a non- smoker and

and clutch linings, rubbish chutes in

unexposed worker)

high rise buildings.


Manufacture of gaskets.
Ship building and repairing e.g. in
lagging and delagging of boilers and

more

than

50

times

when

Cancer of larynx.
Gastro-intestinal
evidence

cancers

(some

particularly

the

oesophagus, stomach, colon)

pipes.
Construction industry e.g. sawing
and grinding of asbestos boards used
in roofing and fireproof
doors/partitions.
Renovation/demolition work e.g. old
buildings, power stations where
asbestos material may have been
used.
Manufacture and repair of brake
linings e.g. car and bus mechanics.
Insulation work e.g. removal or

Asbestos is a confirmed human


carcinogen (IARC 1)
4.0 MEDICAL SURVEILLANCE
PROGRAMME
Please refer to the Factories & Machinery
(Asbestos Process) Regulations 1986.
Any occupation where workers are liable to
be exposed to airborne asbestos fibers
above PEL or possibility of absorption.
4.1 PRE- PLACEMENT MEDICAL
EXAMINATIONS

replacement of asbestos insulation of

Clinical examination and baseline data with

furnaces, ovens etc.

particular emphasis on the:

Department of Occupational Safety and Health (DOSH) Malaysia

16

Guidelines On Medical Surveillance

Respiratory system (medical,

5.0 INDICATIONS FOR MEDICAL

occupational, smoking history, exert

REMOVAL PROTECTION

ional dyspnoea, basal crepitations)

An early state of asbestos induced


disease or diseases have occurred

Pulmonary function test by

A worker is symptomatic

spirometry, forced vital capacity

There is progressive deterioration in

(FVC), forced expiratory volume in


one second

CXR findings in a worker less than 35

(FEV1).

years old

Full-size chest x-ray examination

All cases recommended for MRP and

(350 mm by 430mm)

definite or suspected cases of asbestosis


or

4.2 PERIODIC MEDICAL

mesothelioma

and

bronchogenic

carcinoma must be notified to the DG

EXAMINATIONS
Annual clinical examination with
particular emphasis on the lungs
(basal crepitations). Ask for any
history of exertional dyspnoea

(DOSH).
6.0

FOLLOW-UP ACTION

6.1 ABNORMAL RESULTS


Cases of suspected asbestosis
(category 1/0*) should have a repeat

Repeat full-size chest x-ray


examination if indicated and once in
36 months.

full- size chest x-ray and clinical


examination after one year.
Cases of definite asbestosis

Note: It is not yet established whether


the disease can be diagnosed at a stage
when progression would cease if further
exposure to asbestos is avoided.

(category 1/1 or above* in 2)


Consecutive films should be
followed up annually (full size chest
x-ray and clinical examination) or
more frequently to exclude
complications.

4.3 WHERE INDICATED, THE


FOLLOWING TESTS MAY BE
DONE
Sputum

6.2 MEDICALLY REMOVED WORKER


AND RETURN TO WORK
Recommend the worker for return to

examination

for

asbestos

bodies, abnormal cells.


Carbon monoxide transfer factor

work when the workplace hygiene is


safe and healthy and does not place
the worker at increased risk of
material impairment to health from
exposure to Asbestos.

Department of Occupational Safety and Health (DOSH) Malaysia

17

Guidelines On Medical Surveillance

Suspended asbestosis cases should


be followed up annually or more

8.0 REFERENCES
1.

The Factories and Machinery

2.

Gilson JC: Asbestosis In:

frequently to exclude complications.

(Asbestos Process) Regulations 1986.

Note: *The chest radiographs should be

Encyclopedia of Occupational Health

compared with the set of standard films of

and Safety International Labour Office

ILO 1980 (Classification of Radiographic

Geneva, 3rd edition; 1983 : 187-91.

appearances of the Pneumoconiosis.

3.

Reference No. 6)

Safety and Health: Criteria for a


recommended standard. Occupational

6.3 TREATMENT
There is no definitive treatment for

exposure to asbestos. U .S.


Department of Health, Education and

asbestosis.

Welfare, USA, 1972 (HSM 72-10267).

All cases of suspected bronchogenic


cancer or mesothelioma should be

National Institute for Occupational

4.

International Labour Office:

referred to specialist for further

Occupational Safety and Health Series

management in a chest hospital /

No: 30 Asbestos: Health Risks and

clinic.

their Prevention. ILO, Geneva, 1974.

Symptomatic asbestosis cases may

5.

Asbestos, Health and Safety.


Proceedings of the World Symposium

require treatment as and when

on Asbestos, Montreal, Canada, May

indicated.

1982.
7.0

PREVENTIVE MEASURES

6.

ILO U/C International Classification of

Young persons under 18 years of

Radiographs of Pneumoconiosis.

age should not be exposed to

Revised edition 1980.

asbestos.

7.

Occupational Safety and Health series

Workers should be advised to stop

22 (rev 80) (International Labour

smoking as smoking has

Office, Geneva), 1980.

synergistic effect on likelihood of

8.

World Health Organisation:

lung cancer if there is asbestos

Pneumoconiosis In: Early detection of

exposure.

occupational diseases, Geneva, 1986:

Crocidolite is prohibited for all

9-25.

purposes except for research &

9.

World Health Organisation: Screening

analytical purposes in Malaysia.

and Surveillance of Workers Exposed

Appropriate signage.

to Mineral Dusts, editor: G.R. Wagner,


Geneva, 1996.
10. Control of Substances Hazardous to
Health (COSHH) Regulations:

Department of Occupational Safety and Health (DOSH) Malaysia

18

Guidelines On Medical Surveillance

Regulation11-Health SurveillanceAsbestos in The Health and Safety


Fact book Health & safety Executive,
Professional Publishing Ltd. London,
1989: 1/6.
11. Criteria for the diagnosis of
Occupational Lung Asbestos related
lung disease. Diseases, Ministry of
Health 1997:18.

4.

AURAMINE

1.0 SYNONYMS
Tramethyl diaminobenzophenoimide, Aniline
4, 4 (imidocarbonyl) bis (N, N Dimethyl: HCL)
PEL 8hr TWA: 0
Physicochemical properties

Department of Occupational Safety and Health (DOSH) Malaysia

19

Guidelines On Medical Surveillance

Yellow powder
Route of Absorption
Inhalation
Skin, eye

Respiratory system

Urine cytology

4.2 PERIODIC MEDICAL EXAMINATION

Monthly
personnel:

2.0 OCCUPATIONS AT RISK OF


EXPOSURE
Manufacture of Antiseptics & Dyes
3.0 TOXIC EFFECTS
3.1

Headache, coughing, dizziness, difficulty


in breathing
Nausea & Vomiting
Yellow Vision
3.2 CHRONIC EFFECTS
Haematuria- bladder cancer
Central nervous system
Sub-clinical stage with vague symptoms
IARC Group1 Human Carcinogen &
NTP Human Carcinogen

of

exposed

PAP smears of urine

every 6 months,

Cystoscopy where indicated

Annual collection of urine samples


for examinations of cell shed from

ACUTE EFFECTS
Dermatitis & burns, eye & skin irritation

urinalysis

the bladder is recommended.


5.0 INDICATIONS FOR MEDICAL
REMOVAL PROTECTION
All cases recommended for MRP and
suspected cases of poisoning / excessive
absorption must be notified to the DG
(DOSH).
6.0 FOLLOW-UP ACTION
6.1 ABNORMAL RESULTS:
If there are abnormal results, a repeat test
must be done immediately & refer to
urologist.

Tumours in bladder
4.0 MEDICAL SURVEILLANCE
PROGRAMME
Any work where workers are exposed to
auramine.
4.1 PRE-PLACEMENT MEDICAL
EXAMINATION
Clinical examination and baseline data with
particular attention to:

Nervous system

Skin

Eye

6.2 MEDICALLY REMOVED WORKER &


RETURN TO WORK
All suspended cases should have
repeat

urine

examinations

(and

relevant biochemical tests where


indicated) at monthly intervals and
should not return to work until the
signs and symptoms and abnormal
biochemical

results

have

disappeared.
Recommend the worker for return
to work when the

workplace

hygiene is safe and healthy and

Department of Occupational Safety and Health (DOSH) Malaysia

20

Guidelines On Medical Surveillance

does not place the worker at


increased
impairment

risk
to

of

material

health

from

exposure to Auramine.
6.3 TREATMENT
All cases of poisoning must be immediately
removed from exposure and refer for hospital
treatment.

7.0 PREVENTIVE MEASURES


Adequate ventilation
Approved Personal Protective
Equipment
Chemical goggles & Good personal
hygiene
Appropriate signage.
8.0 REFERENCES
1. International Labour Office: Encyclopedia
of

Occupational Health and Safety,

Geneva, 4th edition, 1998.


5.

2. Plunkett, ER Handbook of Industrial

BENZIDINE

Toxicology Heyden, 1987:45.


1.0 SYNONYMS: Para-Diaminodiphenyl,
Diaminobiphenyl
Physicochemical properties: White or
slightly reddish, crystalline powder.
It

is

an

aromatic

amine.

Breakdown

products include oxides of nitrogen.


PEL 8 hr TWA: 0
Route of absorption

Department of Occupational Safety and Health (DOSH) Malaysia

21

Guidelines On Medical Surveillance

Extremely well absorbed through inhalation


& skin. Ingestion.

Specific

Urine cytology examination, blood


& abnormal cells

2.0

OCCUPATIONS

AT

RISK

OF

EXPOSURE
Chemical synthesis
Dyes, textile dyeing & finishing
industry, paper, leather (tanning)
goods
Rubber industries
Analytical laboratories.
3.0 TOXIC EFFECTS
3.1

Urine benzidine

Diagnostic criteria/ investigation


Benzidine (unchanged) in urine is used as
index of exposure. More than 10 g/l in
random urine is an index of exposure.
Determination

bladder cancer screening


Known

Suspect

carcinogen

carcinogen
Cytology

High

Cytology every

every 6

exposure

6 months, RBC

months, RBC

test

3.2 CHRONIC EFFECTS

every

test every 6

months

months

Low

Cytology after 2

depending

exposure

years, then after

circumstances

every 5 years

Cytology

Confirmed human Carcinogen (IARC1)


Central nervous system

its

Recommended guidelines for

Secondary anaemia from haemolysis.

Bladder cancer

or

performed.

Hemorrhagic cystitis, Haematuria.

Dermatitis.

benzidine

metabolites in blood is not routinely

ACUTE EFFECTS

Hepatic disorders.

of

Cytology

Sub-clinical stage of disease presents


with vague symptoms
Source:

4.1 MEDICAL SURVEILLANCE


PROGRAMME
Workers who are exposed to benzedine or
where there is significant risk of absorption.
4.1 PRE-PLACEMENT MEDICAL
EXAMINATION
Clinical examination and baseline data with
particular attention to:
General

Liver function test, kidney function


test, total blood count.

Goldstein MD Chapter 70 Bladder

Carcinogens and Surveillance in Rom WN


Environmental and Occupational Medicine.

4.2 PERIODIC

MEDICAL

EXAMINANTION
Annually as per Pre-placement
5.0 INDICATIONS FOR MEDICAL
REMOVAL PROTECTION
All cases of definite or suspected
poisoning and excessive absorption.
All cases recommended for MRP and
suspected cases of poisoning / excessive

Department of Occupational Safety and Health (DOSH) Malaysia

22

on

Guidelines On Medical Surveillance

absorption

must be notified to the DG

exhaust

(DOSH).

ventilation.

Suitable

collectors to prevent ambient air


contamination.

6.0 FOLLOW-UP ACTION


Good

6.1 ABNORMAL RESULTS

house

keeping

&

occupational hygiene practices

If the levels are excessive, repeat urine


cytology must be done immediately and

Establish restricted areas, inform

referred to the urologist.

employees of adverse effects,


provide Health Hazard alert.

6.2 MEDICALLY REMOVED WORKER &

Provide wash room / shower

RETURN TO WORK

facilities

All suspended cases should have

Use

repeat urine / blood test.

approved

Personal

Protective Equipment.

The worker can return to work if there


are no symptoms and signs of

Prohibited

disease and urine cytology is normal.


Recommend the worker for return to
work when the workplace hygiene is

in

the

use

manufacture

&

purposes

including

use

for

for

all
any

manufacturing process except for

safe and healthy and does not place

research & analytical purposes.

the worker at increased risk of


material impairment to health from

Appropriate signage.

exposure to Benzidine.
8.0 REFERENCES
6.3 TREATMENT

1.

International

Labour

All cases of poisoning must be immediately

Encyclopaedia

of

removed from exposure and referred for

Health and Safety, Geneva, 4th

hospital treatment.

edition, 1998.
2.

7.0 PREVENTIVE MEASURES

Office:

Occupational

Plunkett,

ER

Handbook

Industrial

Toxicology

of

Heyden,

1987: 53-4.

Substitute other less toxic dye for


benzidine
Engineering
chemicals.

controls
closed

for
process

systems, liquid metering systems,


walk-in hoods, and specific local

3.

Employment
Service.

Medical

Occasional

Advisory
Paper

1,

Biochemical Criteria in certain


biological media for selected toxic

Department of Occupational Safety and Health (DOSH) Malaysia

23

Guidelines On Medical Surveillance

substances. Dept. of Employment,


UK, 1974.
4.

National Institute for Occupational


Safety and Health, Occupational
Diseases -USA.

5.

A Guide to their Recognition, Rev


Ed, US Department of Health,
Education
1977.

and

(DREW

Welfare,

USA,

Publication

No

(NIOSH) 77-181).
6.

World

Health

Recommended

Organization.
Health-based

Limits in Occupational Exposure


to

Heavy Metals - Report of a

WHO Study Group, Technical


Report Series 647, 1980.
7.
8.

Http;// www.cdc.gov/niosh
Goldstein MD Chapter 70 Bladder

6.

BERYLLIUM

Carcinogens and Surveillance in


Rom WN Environmental and
Occupational Medicine, Little
Brown & Co. Edition 1992: 881-6.

1.0 SYNONYMS: Glycinum, Glucinium,


Beryllium chloride, Beryllium flouride,
Beryllium nitrate

9.

Mycroft FJ, Hiatt PH. The toxic


hazards of industrial and

PEL 8 hr TWA:

0.002 mg/m3.

Occupational chemicals In: Olson

Physicochemical properties

KR, Poisoning & Drug Overdose

Light greyish white metal, slightly soluble in

by California Poison Control

acids and alkalis. Its salts are mostly white

System, A Lang clinical manual,

& flammable.

Prentice Hall Int. (UK) Ltd.

Route of Absorption

London, 1999:427-42.
10. Information on the Prohibition of
Substances from Certain
purposes. DOSH, 1999:2.

Inhalation- (mainly)
Some through the gastrointestinal tract
Crosses placental barrier and reaches
the foetus

Department of Occupational Safety and Health (DOSH) Malaysia

24

Guidelines On Medical Surveillance

Excretion

Is caused by relatively insoluble

Via urine and faeces

(metallic & its oxide) due to the


allergenic effect.

2.0 OCCUPATIONS

AT

RISK

OF

Disease may develop many years after

EXPOSURE
Ceramic

&

refractory

cessation of beryllium exposure.

products,

Delayed on set up to 20 years.

aircraft engine part production &

Granuloma in lungs pulmonary fibrosis

spacecraft technicians

and in other organs liver, spleen etc.

(Beryllium, copper and other alloys


in

electrical

contacts,

is

switches,

typical.

-Chronic

Beryllium

Disease

welding electrodes) nuclear reactor

Berylliosis (interstitial lung disease)

workers
Metallic alloys workers, cathode

Symptoms:

Ray-tube makers

breathlessness on exertion, fever.

cough,

dyspnoea,

and

Beryllium extraction
Signs: Rapid weight loss later.

Lithography for electronics.


3.0 TOXIC EFFECTS

There

is

limited

evidence

of

carcinogenicity in humans

3.1 ACUTE EFFECTS


Is caused by Beryllium (chloride,

(IARC 1), ACGIH A1

sulphate, fluoride) inhalation


Beryllium
Cough,

nasopharyngitis,

is

carcinogen

in

test

animals.

tracheobronchitis, bronchiolitis, and


pneumonitis pulmonary oedema a
few

hours

to

1-2

days

after

exposure.
Inhalation causes bronchitis, severe
pneumonitis
irritation

allergic

ulcer,

granuloma.

PROGRAMME
Any work where workers are exposed to
be in excess of half the -in-air standard,

contact

dermatitis, Conjunctivitis
Sensitizer,

MEDICAL SURVEILLANCE

levels of airborne levels, which are liable to

Nasal septum perforation


Skin

4.0

subcutaneous

and or where there is significant risk of


absorbing it.
Diagnostic criteria/ investigation
Chest

X-rays-

diffuse,

bilateral,

granulomatosis, or in early stages


3.2 CHRONIC EFFECTS

only

enlarged

lymph

nodes.

Radiologist report is necessary.


Department of Occupational Safety and Health (DOSH) Malaysia

25

Guidelines On Medical Surveillance

Atopic subjects & persons with respiratory

Pulmonary function Tests


Respiratory function is impaired by

diseases are considered by some as


especially vulnerable.

reduction in diffusion capacity of the


lungs, which is detectable in early
stages of the disease.

4.2 PERIODIC MEDICAL EXAMINATION


The tests same as for pre-placement
examinations Conducted annually or if

Beryllium in urine does not confirm


exposure as those not occupationally
exposed can have concentrations

exposure is heavy much more frequently


4.3 WHERE

usually less than 1 mg/l.

INDICATED,

THE

FOLLOWING TESTS MAY BE DONE

Urine Beryllium is a useful adjunct to

Full blood count

occupational hygiene programme.

It is

Urine

more

with

Lung biopsy

these

Beryllium patch test may not be

than

significant

1mg/l

among

exposure,

those

although

specific.

concentrations do not correlate well with


the extent of exposure or potential for
toxicity. In the absence of clinical signs and

5.0 INDICATIONS FOR MEDICAL

symptoms, the presence of beryllium is not

REMOVAL

a sign of disease.

PROTECTION

All cases of definite or suspected


poisoning and excessive absorption.

4.1 PRE-PLACEMENT MEDICAL


EXAMINATION
At present , laboratory tests are not
available

to determine susceptibility to

beryllium sensitization and the potential to

All cases recommended for suspension


and

suspected

cases of poisoning /

excessive absorption must be notified to


the DG (DOSH).

develop clinical examination and baseline


6.0

FOLLOW-UP ACTION

This should include a medical

6.1

ABNORMAL RESULTS:

history. Physical examination with

If the urine level exceeds, a repeat test

data with particular attention to:

particular attention to atopy and


allergic skin respiratory diseases.

Chest X-ray and basic pulmonary


function tests (FEV 1, FVC) are
also essential.

must be done immediately.


6.2 MEDICALLY REMOVED WORKER &
RETURN TO WORK
All suspended cases should have
repeat tests

Department of Occupational Safety and Health (DOSH) Malaysia

26

Guidelines On Medical Surveillance

Workers

should

not

have

2.

Beryllium

induced

lung

disease,

symptoms & signs of disease at the

Criteria for Diagnosis of Occupational

time of return to work.

Lung Disease Ministry of Health, 1997:

Recommend the worker for return

26.

to

work

when

the

workplace

hygiene is safe and healthy and

3.

Occupational

does not place the worker at

Guideline

increased

compounds

risk

of

material

for

Safety

and

Beryllium
Potential

Health
and

its

Human

impairment to health from exposure

Carcinogen. US Dept. of Health and

to Beryllium.

Human Services, CDC, NIOSH 1988.

6.3 TREATMENT

4.

Information Notices on Diagnosis of

In acute berylliosis, contact with beryllium

Occupational Disease for European

must

CommissionL-2920

be

discontinued.

Since

mild

Luxembourg

symptoms precede a severe attack, the

Office for Official Publications of EU

patient must be admitted to the hospital.

1994: 1.6.
5.

7.0 PREVENTIVE MEASURES

Plunkett E R Handbook of Industrial


toxicology, Industrial Health Services
Barberton, Ohio. 1987: 155-6.

Improvement in work process


Workplace hygiene

6.

Diseases caused by beryllium and its

Adequate ventilation, mechanical

toxic compounds In Early Recognition

filter respirator, Pressurized suit in

of Occupational Diseases World

particularly

Health Organisation; 1986: 44 -7.

hazardous

places,

compulsory changing of working


clothes, wear chemical goggles,
Rubber gloves
Appropriate signage

8.0 REFERENCES
1.

Baselt

RC

Methods
Biomedical

for

Biological

Monitoring

Industrial

Chemicals

Publications,

Davis,

California 1980: 47.

Department of Occupational Safety and Health (DOSH) Malaysia

27

Guidelines On Medical Surveillance

7. CADMIUM AND ANY OF ITS


COMPOUND
1.0 Physicochemical properties
Cadmium is a soft, ductile, white metal
with a bluish tinge.
PEL 8 hr TWA
Elemental

0.01 mg/m3

Compounds 0.002 mg/m3


(respirable

fraction)

Route of absorption
Inhalation, Ingestion (in condition of
poor general hygiene).
Non-occupational exposure
Cadmium is widely present in the diet
and especially from smoking.
Excretion

Department of Occupational Safety and Health (DOSH) Malaysia

28

Guidelines On Medical Surveillance

Elimination is slow, with half-life of >10

Smelting and refining of Zn, Pb or

years: it takes place via the kidneys.

Cu ores and scrap processing.

Cadmium is held in the body to small


protein, metallothionein, mostly in the

3.0 TOXIC EFFECT


3.1

kidneys and liver.

ACUTE EFFECT

Chemical pneumonitis following fume


2.0

OCCUPATIONS AT RISK OF
EXPOSURE
Nickel-cadmium

inhalation; onset

battery

manufacturing

(tabletting

and

assembly of Cd electrodes).
Silver

brazing,

soldering

welding

operations

cadmium-containing fillers.
Plastics

industry,

especially

Metal Fume

Fever.
Gastrointestinal tract irritation following
accidental ingestion.

and
using

within 8 to 24

hours; mortality 15%.

3.2 CHRONIC EFFECTS


Renal

compounding of polyvinyl chloride


(PVC); used as thermal stabiliser.

dysfunction

(tubular

or
low

glomerular

damage

with

molecular

weight

proteinuria,

glucosuria,

amino

aciduria,

albuminuria and reduced creatinine


Electroplating. (metallic Cadmium is
used)
Pigment manufacture and use, e.g.
for plastics, textile, paper, rubber
industries;

in

inks,

enamels

&

glazes
Alloy manufacture, e.g. low meltingpoint brazing alloys, Ag-Cd & CuCd
Manufacture of refrigerators, airtelevision

picture

tubes, semiconductors, photocells


&

fluorescent

neutron

lamps,

absorber

in

and

Kidney stones
Emphysema
Bone

pain

(Itai-Itai,

Ouch-Ouch

Disease), osteomalacia & fractures.


Anosmia
Note: Cigarette smoking adds to cadmium
burden. Each cigarette contains about 1 -2
ug cadmium (Cd) of which approximately
25 -50% is retained in the lungs.

Fungicides manufacture and use


conditioners,

clearance)

as

nuclear

reactors.
Jewelry manufacture
Automobile and aircraft industries

The

average

normal

gastrointestinal

absorption in man ranges from 3 -7% of


ingested cadmium. This increases to as
high as 20% with nutritional deficiencies of
calcium, iron or protein.
4.0 MEDICAL SURVEILLANCE
PROGRAMME

Department of Occupational Safety and Health (DOSH) Malaysia

29

Guidelines On Medical Surveillance

Any work where workers are exposed to

Skeletal system

levels >

Renal system

50 % PEL or where there is

significant risk of absorbing cadmium.

Hb, creatinine
Blood cadmium estimation (venous

BIOLOGICAL EXPOSURE
DETERMINANTS
Determinants
Cadmium in

Sampling
time
Not critical

urine
Cadmium in

blood in heparinised container)


BEI
5g/g

creatinine
Not critical

5g / L

blood
Source: TLVs & BEIs ACGIH, 2000
4.1

Urine: Cadmium concentration, classic


urine

analysis,

determination

of

including

specific

protein

concentration i.e.
Urine Beta2 -microglobulin estimation.
DO NOT USE EARLY MORNING
SPECIMEN.

Collect

morning

specimen 2 hours after drinking 15

PRE-PLACEMENT MEDICAL

mI. Mist Potassium Citrate. Discard

EXAMINATION

specimen if urine pH lower than 5.6.

Clinical examination & baseline data ( for


future biologic monitoring) with particular
emphasis on the :
Detailed history of previous diseases
and occupational exposures
especially lung and renal problems &
about previous and present exposure
to lung and kidney toxins ( tobacco,
silica, asbestos, irritant gases,
mercury, lead, etc).
Identification of personal habits
(smoking, hygiene, hobbies, alcohol

Keep

specimen

collection

and

refrigerated after
in

ice

during

transportation.
Specimens should reach the laboratory
within 2 hours after collection.
Persons

showing

signs

of

lung

disturbances and kidney damage should


not be exposed to cadmium.
Since

teratogenic

effects

have

been

produced in animals with high doses of Cd


and since Cd appears to accumulate in
placenta, it may be preferable to prevent
any Cd exposure during pregnancy.

consumption, fingernail biting).


Complete physical examination
Respiratory ( CXR, Lung Function
Tests-FEV 1, VC,V max 50,V max 25
or possibly closing volume
Olfactory sense .
Evaluation of the ability of the
individual to use respiratory protective
devices

4.2 PERIODIC MEDICAL EXAMINATION


Depending on the risk of overexposure to
Cd (based on workplace air monitoring
analyses) a medical assessment should be
performed at interval of 3 months first year
of exposure and at interval of 6 month
thereafter. Its purpose is threefold:

Department of Occupational Safety and Health (DOSH) Malaysia

30

Guidelines On Medical Surveillance

(a) Detection of early biological effects of


Cd

Urine examination for albumin and

(b) Detection of excessive exposure to Cd


before the occurrence of significant
biological effects

phosphates and amino acids and

(c) Detection of non-occupational related


diseases that would justify reduction of
Cd exposure.

Full-size chest x-ray and lung function

transferrin,
microscopic

tests (FEV 1 and FVC)

pelvis

Periodic-exposure to airborne cadmium


oxide fumes
including :
to

elicit

respiratory

symptoms

Blood pressure measurement


Serum creatinine and urea estimation
Creatinine clearance estimation.
5.0

of

suspected

cadmium

All

cases

of

renal

dysfunction

estimation

All

cases

with

abnormal

lung

function

DONE:
(early

morning specimen collected in acidwashed container and corrected to


or

cases

(tubular or glomerular)

FOLLOWING TESTS MAY BE

1.016

INDICATIONS FOR MEDICAL


REMOVAL PROTECTION

4.3 WHERE INDICATED, THE

of

and

poisoning and excessive absorption.

Chest X-ray

cadmium

osteomalacia

Haemoglobin estimation

All

Lung function testing- spirometry

(for

fractures)

This needs annual consultation with OHD

SG

urine

X-rays of long bones, scapula and

Urine test for protein (total) and beta -2


microglobulin)

Urine

examination,

protein electrophoresis.

(e) Urine Cd level

Questionnaire

calcium,

Abdominal X-ray (for renal stones) and

(d) Blood Cd level

(f)

glucose,

creatinine

concentration).
Urine examination for total protein
using the Trichloroacetic acid (TCA)
test (To 1 mI urine add l00ul 25%
TCA. Mix and read turbidity against
protein standards of 10 mg -100
mg/dl); early morning specimen.

Cases with blood cadmium levels of


more

than

15

g/litre

in

successive examinations.
Cases with urine cadmium levels of
more than 15 g/gm creatinine in 2
successive examinations
Cases with urine Beta2-microglobulin
g/litre

exceeding

300

creatinine

correction.

with
in

successive examinations
All cases with evidence of cancer
(lungs)

Department of Occupational Safety and Health (DOSH) Malaysia

31

Guidelines On Medical Surveillance

All cases recommended for removal and

For return to work with cadmium work the

suspected cases of cadmium poisoning /

criteria are:

excessive absorption or cancer must be

Parameter

Level

6.0 FOLLOW-UP ACTION

Symptoms & signs


cadmium
Poisoning

Not present

6.1

Blood cadmium

notified to the DG (DOSH).

ABNORMAL RESULTS
If the blood cadmium level exceeds
10 g/litre, a repeat blood cadmium
test must be done immediately
together

with

urine

cadmium

<10 g/litre

Urine cadmium

10 g/gm
creatinine

Urine Beta2
microglobulin

300 g/gm
creatinine

estimation and creatinine clearance


test.

6.3 TREATMENT

If the urine Beta2-microglobulin result

All cases of cadmium poisoning must be

exceeds 300 g/gm creatinine, a

immediately removed from exposure. Acute

repeat test should be done one

poisoning cases must be referred for

month later.

hospital treatment. There is no suitable


antidote.

6.2 MEDICALLY REMOVED WORKER &


RETURN TO WORK

7.0 PREVENTIVE MEASURES


Improvement in -work process

All suspended cases should have repeat

Improvement in workplace hygiene

blood and/or urine cadmium and/or urine

(ventilation)

Beta2-microglobulin examinations, where

Use of approved PPE

indicated, at 3-monthly intervals.

Appropriate signage

Cases

with

definite

evidence

of

permanent renal or lung damage or

8.0 REFERENCES

cancer should preferably not continue

1.

Phoon WH, Magdalene Chan, Ho SF,

with cadmium work.

Lee HC Dept of Industrial Health

Recommend the worker for return to

Guidelines For Designated Factory

work when the workplace hygiene is

Doctors-The

safe and healthy and does not place

Examinations) Regulations Dept of

the worker at increased risk of

Community, Occupational and Family

material impairment to health from

Medicine,

exposure to cadmium.

Singapore 1997.

Department of Occupational Safety and Health (DOSH) Malaysia

Factories

National

(Medical

University

32

of

Guidelines On Medical Surveillance

2.

Threshold Limit Values (for Chemical

Professional Publishing Ltd. London,

Substances and Physical Agents) and

1989: 1/5-1/7.

Biological Exposure Indices, American


College

of

Government

Industrial

Hygienists (ACGIH), Cincinnati, Ohio,


USA. 1999.
3.

National

Institute

for

Occupational

Safety and Health: Criteria for a


recommended standard. Occupational
exposure to cadmium, US Department
of Health, Education and Welfare,
USA, 1976 (HEW

Publication No

8. CARBON DISULPHIDE

(NIOSH) 76 -192).
4.

International

Labour

Office:

Encyclopaedia of Occupational Health


and Safety, Geneva, 4th edition, 1998.
5.

6.

PEL 8 hr TWA:

10 ppm

Physicochemical properties

Friberg L., Piscator M., Nordberg G.

Colourless liquid, sweetish aromatic odour.

F., Kjellstrom T: Cadmium in the

Commercial and reagent grade is a

environment, edition 2, Cleveland,

yellowish liquid with a foul smell. It is

Ohio, Chemical Rubber Co, 1974.

volatile and flammability, boiling point,

World

Organisation:

melting point and its vapours are explosive.

Recommended Health Based Limits in

Often with offensive rotten cabbage odour.

Health

Occupational

exposure

to

heavy

metals -Report of a WHO Study


Group, Technical Report Series 647,
1980.
7.

1. 0 SYNONYMS: Carbon Bisulphide

Cadmium and Health: A Toxicological


and Epidemiological

Route of absorption
Inhalation & dermal
Mode of toxic action
1.

Enzyme inhibition via sulfhydryl groups

2.

Proliferation of vascular endothelium

3.

Fatty

Appraisal Vol. I

and n. 1985.

producing general arteriosclerosis


degeneration

of

liver,

Glomerulosclerosis, CNS depression.


8.

Control of Substances Hazardous to


Health

(COSHH)

Regulations:

Regulation11-Health

Surveillance-

Cadmium in The Health and Safety


Factbook Health & safety Executive,

Optic neuritis.
Metabolism and Excretion
A variable portion (10-30 %) is exhaled
unchanged, the majority is metabolised.
Three major

Department of Occupational Safety and Health (DOSH) Malaysia

metabolites appear in urine

33

Guidelines On Medical Surveillance

of

which

2-thiothiazolidine-4-carboxylic

acid (TTCA) accounts for 6 % of absorbed


dose.
2.0 OCCUPATIONS AT RISK OF

Prolong exposure:

General

Headache Dizziness

CNS

Encephalopathy,
Parkinsonism.

EXPOSURE
Adhesives,

Chemical

Disinfectant,

Deafness

synthesis,

Extraction,

Solvent

in

Psychiatric

laboratories and industrial processes,

Central scotoma,

varnishes, Perfumes, in Viscose Rayon


industry as a solvent of alkaline cellulose,
resins, rubber.

Eyes

Extremely

Toxic

Potent

3.1 ACUTE EFFECT

Peripheral

Polyneuritis:

nervous

sensory nerves of lower

system

extremities,

on

CNS

Heart

of

leading to arteriosclerosis
heart attacks & poor

Narcosis, behaviour disorders,

circulation in extremities.

hallucinations, delirium,

Cardiomyopathy

progressive paralysis and

Eyes

Loss

Increases fat levels and

skin,

flushing of skin

&

extremities, paralysis

vomiting, abdominal pains


action

Motor

sensation & weakness of

Headache, dizziness, nausea,

Vesicant

colour, Field Disturbed


blindness

neurotoxin

Skin

Concentric contraction of
stereoscopic vision,

3.0 TOXIC EFFECTS

General

Emotional disturbance and


psychosis

Insecticides, Herbicides, Lacquers and

General:

At high concentration

cause damage to many body systems.

death due to respiratory

Gastro-

paralysis

Intestinal

Irritant,

keratitis

and

Conjunctivitis

3.2 CHRONIC EFFECTS: After 10 - 15

and neurological problem

decrease

free

hepatotoxic,

HCL,
GIT

dysfunction
Genito-

Microhematurias,

urinary:

albuminuria, hypertensive
nephrosclerosis

years
Long term: Low exposure results in mental

Anorexia, chronic gastritis,

Endocrine

Reduced adrenal function


due to reduced secretion of
corticotrophins

Department of Occupational Safety and Health (DOSH) Malaysia

34

Guidelines On Medical Surveillance

i.

In woman Hormonal
Reproductive

Iodine Azide
Test

disturbance, menstrual

Positive:

irregularities, spontaneous

if exposure level > 50 mg

CS2/m3

abortions & premature

Negative; if <50 mg CS2/m3

deliveries

ii. Measurement of Carbon Disulphide

In Man: impaired

iii. DTS

spermatogenesis

Air concentration of CS2 and effects

BIOLOGICAL EXPOSURE

on man

DETERMINANTS

Air concentration
of CS2 mg/m 3
10-60

Effects
Physiological
disturbances

At exposure levels
> 50

The iodine -azide


test reflects
exposure

60-90

Psychological
symptoms

30-125

Vascular
effects

Source: WHO Early Recognition of


Occupational Diseases Geneva.1986

Determinants
2-Thiothiazolidine4-carboylic acid in

Sampling
time
End of
shift

urine (TTCA)

BEI
5mg /g
creatinine

Source : TLVs & BEIs ACGIH 2000

Biological Monitoring with Effect


i. Neurophysiological changes EMG
and nerve conduction study.
Finding - Reduced in conduction.
ii.

Neurobehavioral change from heavy


psychiatric and neurological

4.0

MEDICAL SURVEILLANCE

symptomatology

PROGRAMME
Any work where workers are exposed to
levels of airborne levels, which are liable to

4.1

PRE-PLACEMENT MEDICAL
EXAMINATION

be in excess of half the -in-air standard, and

Clinical examination and baseline data

or where there is significant risk of absorbing

condition with special attention to :

it.

Cardiovascular systems.

Biological Monitoring and exposure

Nervous system and

Department of Occupational Safety and Health (DOSH) Malaysia

35

Guidelines On Medical Surveillance

Exercise

ECG-

to

detect

early

6.2

WORKER & RETURN TO WORK

evidence of heart disease


Serum

high

density

lipoprotein

All suspended cases should have

cholesterol

repeat urine examinations (relevant

Opthalmoscopy
4.2

MEDICALLY REMOVED

biochemical tests where indicated)

PERIODIC

at (3-monthly intervals if required)

MEDICAL

and should not return to work until

EXAMINATIONS

the urine / blood level falls below

These should be carried out once a year.

5mg /g creatinine and symptoms

Medical element including

and abnormal biochemical results

Psychological testing

have disappeared.

to aid early

detection of behaviour disorders

Recommend the worker for return

Measurement of nerve conduction


velocities

to

detect

to work when the

sub-clinical

peripheral neuropathy
Colour

vision

testing-

does not place the worker at

colour

increased

discrimination is reported in exposed

risk

of

material

impairment to health from exposure

workers.
4.3

workplace

hygiene is safe and healthy and

to chemical hazardous to health.

OTHER INVESTIGATIONS

6.3

TREATMENT

Liver function test

First Aid.

Adrenal function test

Irrigate eyes with water.

Urine analysis

Wash contaminated areas of body with

5.0

INDICATIONS

FOR

MEDICAL

REMOVAL PROTECTION

All cases of definite or suspected


poisoning

and

excessive

absorption
All cases recommended for MRP and
suspected cases of poisoning / excessive
absorption must be notified to the DG
(DOSH).
6.0
6.1

soap and water.


7.O

PREVENTIVE MEASURES
Adequate ventilation
Approved PPE - Suitable
rubber

gloves,

and

goggles,
chemical

cartridge respirator.
Prohibited

for

the

cleaning

and

degreasing purposes
Appropriate signage.

FOLLOW-UP ACTION

8.0 REFERENCES

ABNORMAL RESULTS:
Confirm suspected abnormality.
Department of Occupational Safety and Health (DOSH) Malaysia

36

Guidelines On Medical Surveillance

1.

Phoon WH, Magdalene Chan, Ho SF,


Dept of Industrial Health Guidelines
For Designated Factory Doctors-The
Factories

(Medical

Regulations

Dept

Examinations)
of

Community,

Occupational and Family medicine


National University of Singapore 1997.
2.

Plunkett E R Handbook of Industrial


toxicology, Industrial Health Services
Barberton, Ohio. 1987: 86-8.

3.

International

Labour

Office:

9.

DISULPHUR DICHLORIDE

Encyclopaedia of Occupational Health


th

and Safety, Geneva, 4 edition, 1998.


4.

Early Recognition of Occupational


Diseases, WHO Geneva 1986: 97.

5.

1.0 SYNONYMS : None


Route of Absorption
Inhalation

Control of Substances Hazardous to

Dermal

Health

Regulations:

Confirmed carcinogen (IARC 1) Bladder

Surveillance-

tumours

(COSHH)

Regulation11-

Health

Carbon Disulphide in The Health and


Safety Factbook

Health

Executive , Professional

&

safety

Ltd London,1989:1/8.
6.

Information

on

the

EXPOSURE
3.0 TOXIC EFFECTS

Prohibition

of

Substances from Certain purposes.


DOSH,1999:5.

2.0 OCCUPATIONS INVOLVING RISK OF

Publishing

3.1 ACUTE EFFECTS


3.2 CHRONIC EFFECTS
Bladder tumours
4.0 MEDICAL SURVEILLANCE
PROGRAMME
Any work where workers are exposed to
airborne levels and are liable to inhale it or
where there is significant risk of absorbing
it.

Department of Occupational Safety and Health (DOSH) Malaysia

37

Guidelines On Medical Surveillance

Please refer to

the recommended

6.2 MEDICALLY REMOVED WORKER &

guidelines for bladder cancer screening

RETURN TO WORK

as in page 14.

All suspended cases should have


repeat

4.1

investigation

examinations

PRE-PLACEMENT MEDICAL

urine

and

relevant

biochemical tests where indicated

EXAMINATIONS

and should not return to work until

Clinical examination and baseline data with

the

particular attention to:

abnormal biochemical results have

and

symptoms

and

disappeared.

Kidneys

Recommend the worker for return

Neurological

to work when the

Respiratory system.
4.2

signs

PERIODIC

hygiene is safe and healthy and


does not place the worker at

MEDICAL

increased

EXAMINATIONS

Urine cytology to be done annually but


if exposure is high carry it out more
frequently.
Bladder cystoscopy if indicated.
FOR

risk

of

material

impairment to health from exposure

As for Pre-employment

5.0 INDICATIONS

workplace

MEDICAL

REMOVAL PROTECTION

to disulphur dichloride.
6.3 TREATMENT
All cases of poisoning must be immediately
removed from exposure and referred for
hospital treatment.
Wash contaminated areas of body with
soap and water.

All cases of definite or suspected


poisoning or disease and excessive

7.0

absorption.

Improvement

All cases recommended for MRP and


suspected

in

work-process

&

workplace hygiene

cases of poisoning /

Adequate ventilation

excessive absorption must be notified

Approved Protective equipment

to the DG (DOSH).

Chemical goggles

6.0 FOLLOW-UP ACTION


6.1

PREVENTIVE MEASURES

Appropriate signage

ABNORMAL RESULTS

If abnormal symptoms & signs persist, a

8.0

REFERENCES

repeat test must be done immediately.

1.

International

Labour

Office:

Refer to urologist for abnormal urine

Encyclopaedia of Occupational Health and

cytology.

Safety, Geneva, 4th edition, 1998.

Department of Occupational Safety and Health (DOSH) Malaysia

38

Guidelines On Medical Surveillance

10. BENZENE INCLUDING BENZOL


1.0 SYNONYMS
Benzol (crude benzene), Benzole, Benzonine,
Phenyl Hydrate, Bicarbonate of Hydrogen,
Cold Naphta
It is a an aromatic hydrocarbon & is a
natural component of crude and refined
petroleum
PEL 8 hr TWA: 0.5 ppm
Physicochemical Properties
Colorless, volatile, with sweet aromatic
odour.
Route of entry
Inhalation
Skin
Ingestion
Crosses the placenta
Excretion
Metabolism is the main route: about 12% is
exhaled unchanged with the triphasic
pattern
(Half-lives of 25 mins, 2.5 hours and 30
hours)
One third of the absorbed dose appears
rapidly in urine having been metabolised to
phenols.

Department of Occupational Safety and Health (DOSH) Malaysia

39

Guidelines On Medical Surveillance

2.0 OCCUPATIONS AT RISK OF

Non-specific

EXPOSURE

manifestations

e.g.

anorexia, headache, dizziness

Petrochemical

industries

manufacture

of

e.g.

Bone marrow depression (Levels of


100-500 ppm)

benzene,

production of carbon black

Leucopoenia,

thrombocytopenia,

Petroleum refineries

anaemia, pancytopaenia aplastic

Is a constituent of gasoline

anaemia

Re-bottled gasoline

Skin

irritation

contact)

sellers.

dry,

(repeated
scaly

skin

dermatitis

erythema and/or blistering


Nervous

system-inflammation

of

nerves
Used as a solvent in manufacture
of

plastics,

synthetic

Ventricular Arrhythmia

fibers,

detergents, synthetic resins

Others conditions

Laboratories e.g. use of benzene in

It is a known human carcinogen (ACGIH

analytical techniques, is a solvent

A1)
Acute

for fats

myeloid

Work involving use of commercial

common

solvents such as toluene and xylene

leukemia)

being

(Benzene may be present as a

Lymphoma

contaminant)

Multiple myeloma

Leukemia
acute

(most
myeloid

In glue used in shoe manufacture


Used as a solvent in paint stripping
Used

in

carburetor

cleaning

4.0

MEDICAL SURVEILLANCE
PROGRAMME

Any occupational exposure to benzene &

purposes.

benzol
3.0

TOXIC EFFECTS

3.1

ACUTE EFFECTS (500-1000 ppm)

Narcosis,

nausea,

tremors,

unconsciousness, death.
Levels of 20,000 are fatal to humans within
5-10 min.
Skin and mucous membrane irritation
3.2 CHRONIC EFFECTS

4.1 PRE-PLACEMNT MEDICAL


EXAMINATIONS
Clinical examination and baseline data with
particular emphasis on the hematological
and central nervous systems.
General
Haemoglobin and full blood count
(total white blood cells, red blood

Department of Occupational Safety and Health (DOSH) Malaysia

40

Guidelines On Medical Surveillance

cells and platelets, especially for


those who are exposed to high levels
of benzene

Urinary phenol

End of shift

> 50 mg/L

End of shift

creatinine

End of shift

500g/

S-Phenylmercapturic
acid in urine

Specific
Full blood Picture & Peripheral blood
film (to look also for blast cells)

25g/

(S-PMA)
t, t Muconic
acid in urine

Urinary phenol estimation

creatinine

It is a useful indicator for monitoring


workers exposure (if diet is carefully

Source: TLVs & BEIs ACGIH, 2000.

controlled for phenol products)


A spot urine phenol > 20 mg/L suggests
occupational exposure.
4.2 PERIODIC

4.3 WHERE INDICATED OTHER TESTS


MAY BE DONE
Bone marrow biopsy

MEDICAL

EXAMINATIONS

Liver function test

increased to 6 monthly (If exposure > TLV-

INDICATIONS FOR MEDICAL


REMOVAL PROTECTION
All cases of definite or suspected

every 6 month) or even 3 monthly intervals

poisoning and excessive absorption

Annual, but the frequency of test may be

if exposure is heavy. The content should be


the same as at the pre-placement

5.0

Cases with urine phenol levels of


more than 50 mg/L

Full blood picture

Urinary phenol

Urinary trans-muconic acid and s-

(Or 50 mg/g Cr) in 2 successive

phenylmercapturic acid (S-PMA)

examinations
Cases of anemia and/or leukemia

more sensitive and specific tests

All cases recommended for MRP and

for measurement of low levels of

suspected cases of benzene poisoning /

benzene exposure.

excessive absorption or cancer must be


notified to the DG (DOSH).

BIOLOGICAL EXPOSURE

6.0 FOLLOW -UP ACTION

DETERMINANT

DETERMINANT

6.1 ABNORMAL RESULT


SAMPLING
TIME

BEI

Blood count or peripheral blood film should


be referred to exclude effects

Department of Occupational Safety and Health (DOSH) Malaysia

due to

41

Guidelines On Medical Surveillance

benzene even if the urine phenol level is


below 50 mg/L (or 50 mg/g Cr).

work in areas where there

6.2 MEDICALLY REMOVED WORKER &

is

RETURN TO WORK

significant

benzene

exposure.

All suspended cases should have:

Workers

Repeat urine phenol estimations at

should

monthly intervals

as

The

cigarette

worker may return to work

smoke

not

smoke

from

one

contains 60-80

urine

g of benzene: a typical

phenol level falls below 50 mg/L (or

smoker inhales 1-2 mg of

50 mg/g Cr) &

benzene

Haematological results are normal

confound low-level benzene

Recommend the worker for return

exposures.

with

benzene

when

the

to work when the

may

Benzene is prohibited for

does not place the worker at


risk

This

workplace

hygiene is safe and healthy and


increased

daily.

of

cleaning

material

impairment to health from exposure

&

degreasing

purposes in Malaysia.

to benzene.
7.0

PREVENTIVE MEASURES
Young

persons

years

of

under
age

pregnant/nursing

8.0 REFERENCES
18

Lee HC Dept of Industrial Health

and

Guidelines For Designated Factory


Doctors-The

mothers

(Medical

Community, Occupational and Family


Medicine,

benzene.

National

University

of

Singapore 1997:6.3.1-4.

Workers with liver disease


anemia

Factories

Examinations) Regulations Dept of

should not be exposed to

and/or

Phoon WH, Magdalene Chan, Ho SF,

should

not

International

Labour

Office:

Encyclopaedia of Occupational Health

Department of Occupational Safety and Health (DOSH) Malaysia

42

Guidelines On Medical Surveillance

and

Safety,

Geneva,

3rd

edition

Volume 1, 1983: 257-61.

benzene in The Health and Safety


Factbook Health & Safety Executive,
Professional Publishing Ltd London,

National

Institute

for

Occupational

1989-1/7.

Safety and Health: Criteria for a


Recommended Standard Occupational

10 A Buchwald Benzene in Poisoning &

exposure to Benzene, US Department

Drug overdose Olson KR a Lang

of Health, Education and Welfare

clinical manual 1999:104-5.

1974: 74-137.
11 Information
4

Robert

R.

Lawerys:

Industrial

Chemical Exposure Guidelines for

on

the

Prohibition

DOSH, 1999:4.

Biological Monitoring, 1983: 47-54.


5

Richard S. Brief et al: Benzene in the


Workplace. Am Ind. Hyg. Assoc.,
Vo141, 1980:616-623.

Threshold Limit Values (for Chemical


Substances and Physical Agents) and
Biological Exposure Indices, American
College

of

Government

Industrial

Hygienists (ACGIH), Cincinnati, Ohio,


USA, 1999.
7

Swaen GMH and Meijer IMM: Risk


Assessment

of

Leukaemia

and

Occupational Exposure to Benzene.


BJIM; Vol46 No.12: 1989: 826-830.
8

Guidelines for health surveillance for


benzene NOHSC: 7039(1995). Jan
1996.

Control of Substances Hazardous to


Health

(COSHH)

Regulations:

Regulation11-Health

Surveillance-

of

Substances from Certain Purposes

Department of Occupational Safety and Health (DOSH) Malaysia

43

Guidelines On Medical Surveillance

11. CARBON TETRACHLORIDE


1. 0 Synonyms: Perchloromethane,
Tetrachloromethane
PEL 8HR TWA: 5 ppm
Physicochemical properties
Heavy colourless, non-flammable liquid
Ether like odour is a poor warning property
Breakdown

products

include

hydrogen

chloride, chlorine gas


and phosgene.
Route of Absorption
Inhalation as vapour
Dermal
Ingestion.
2.0 OCCUPATIONS AT RISK OF
EXPOSURE
Adhesives, Chemical synthesis, Fire
extinguisher
Fumigant, solvent, dry cleaning solvent,
degreaser, spot remover.
3.0 TOXIC EFFECTS
3.1 ACUTE EFFECTS
Headache & Dizziness,
General

nervousness, Irritant to the


eye, nose, throat

CNS
Department of Occupational Safety and Health (DOSH) Malaysia

Dizzy, unconsciousness and


coma, optic neuritis,

44

Guidelines On Medical Surveillance

coma, optic neuritis,

4.0 MEDICAL SURVEILLANCE


PROGRAMME

Neurosis

Lungs

Dyspnoea and cyanosis,


Pulmonary oedema

Kidney: Destruction of renal


Renal

tubules with nephritic and


nephrotic symptoms oliguria,

Any work where workers are exposed to


levels of airborne levels, which are liable to
be in excess of half the in-air standard, and
or where there is significant risk of
absorbing it.
4.1 PRE-EMPLOYMENT MEDICAL
EXAMINATIONS

proteinuria, haematuria
Nausea, vomiting,
Gastrointestinal

haematemesis, abnormal
cramps and diarrhoea,
cardiac muscle depression
Liver failure/necrosis Hepatomegaly & jaundice

Heart

Cardiac muscle depression

Carbon tetrachloride in serum, urine


and expired air
Increase

Dermatitis

in

glutamic

oxaloacetic

transaminase
Increase BUN
Urinary urobilinogen elevation occurs

Ventricular fibrillation &


sudden death.

Skin

Clinical examination and baseline data with


particular attention to :

after 7-10 days


GC can be used to analyze expired air
Urine

estimation

specimen

(early

corrected

morning

to

serum

creatinine).
3.2 CHRONIC EFFECTS

Preclude from exposure those individuals

Apathy and mental confusion, Headaches

with disease of liver, kidneys and central

and dizziness

nervous system or alcoholism.

Fatigue
Anorexia, nausea, vomiting, abdominal

4.2

pain

EXAMINATIONS

Restriction of visual fields and diminished

In general annual examinations as at the

visual acuity

pre-employment check but for exposed

Loss of weight, Jaundice

personnel every six months if exposure is

Dermatitis

high including studies of :

Evidence of renal damage


A carcinogen in test animals (IARC 2B)

PERIODIC

MEDICAL

Liver (including prothrombin time)


Kidney function

Department of Occupational Safety and Health (DOSH) Malaysia

45

Guidelines On Medical Surveillance

5.0

INDICATIONS FOR MEDICAL

Oxygen and artificial respiration

REMOVAL PROTECTION

Refer to hospital

All cases of definite or suspected


poisoning and excessive absorption.

7.0 PREVENTIVE MEASURES


Attention

All cases with recommended for MRP and

should

be

paid

to

substituting a less toxic chemical for

suspected cases of poisoning / excessive

carbon tetrachloride where possible.

absorption must be notified to the DG


(DOSH).

Adequate

ventilation,

Chemical

6.0

FOLLOW-UP ACTION

goggles,

Chemical

cartridge

6.1

ABNORMAL RESULTS

respirator, Polyvinyl gloves

Repeat tests if the urine level exceeds, a

Avoid

repeat test must be done immediately.

Prohibited

RETURN TO WORK

relevant

examinations

biochemical

tests

abuse

where

should not return to work until the

in

the

cleaning

and

Appropriate signage.

(and

indicated) at 3-monthly intervals and

8.0 REFERENCES
1.

Phoon WH, Magdalene Chan, Ho SF,

urine/blood level are within normal

Dept of Industrial Health Guidelines

limits and symptoms and signs have

For Designated Factory Doctors-The

disappeared.

Factories

Dept

Examinations)
of

Community,

Occupational and Family medicine

work when the workplace hygiene is

National University of Singapore 1997.

safe and healthy and does not place


the worker at increased risk of

(Medical

Regulations

Recommend the worker for return to

6.3

alcohol

degreasing purposes.

All suspended cases should have


urine

as

increases risk of toxicity

6.2 MEDICALLY REMOVED WORKER &

repeat

alcohol

2.

Plunkett E R Handbook of Industrial

material impairment to health from

toxicology, Industrial Health Services

exposure to carbon tetrachloride.

Barberton, Ohio.1987: 89- 91.

TREATMENT

3.

by saline catharsis

Office:

and Safety, Geneva, 4th edition, 1998.

Wash contaminated areas of body with


Gastric larvage, if ingested, followed

Labour

Encyclopaedia of Occupational Health

Irrigate eyes with water


soap and water

International

4.

Control of Substances Hazardous to


Health
Regulation

Department of Occupational Safety and Health (DOSH) Malaysia

(COSHH)
11-Health

Regulations:
Surveillance-

46

Guidelines On Medical Surveillance

Carbon tetrachloride in The Health and


Safety

Factbook

Health

&

safety
12. TRICHLOROETHYLENE (TCE)

Executive, Professional Publishing Ltd


London, 1989-1/9.
5.

Olson KR, Poisoning & Drug overdose


a Lang

clinical manual 1999:127-

129, 449t.
6.

Information

1.0 SYNONYMS:

Acetylene trichloride.

Trichloroethene
PEL 8 hr TWA : 50ppm

on

the

Prohibition

of

Substances from Certain Purposes.


DOSH, 1999:5.

Absorption
It is well absorbed by inhalation: the skin is
a possible route.
Excretion
The majority is metabolised. A small
proportion is exhaled unchanged. The 2
major

urinary

metabolites

are

trichloroacetic acid and trichloroethanol.


Non-occupational exposure TCE May be
present in a few household solvents e.g.
spot removers.
2.0

OCCUPATIONS AT RISK OF
EXPOSURE
Workers

involved

in

vapour

degreasing and cold cleaning of


metal parts in metal fabricating,
automotive, aircraft and aerospace
industries.
Used for cleaning of lenses in optical
industry.
Used as solvent for extraction of
waxes, fats, resins and oils.
Used as a solvent or chemical
intermediate
varnishes,

Department of Occupational Safety and Health (DOSH) Malaysia

in

printing

adhesives,

inks,
plaints,

47

Guidelines On Medical Surveillance

lacquers,

rug

cleaners

and

disinfectants.

Liver
Few cases of hepatitis-like syndromes and
statuses (fatty liver) have been reported

3.0 TOXIC EFFECT

from chronic exposure to trichoroethylene.

3.1 ACUTE EFFECTS

Skin

Nervous system- narcosis, headache,


dizziness, nausea, lack of co-ordination,
mood

changes

(Addictive

potential).

Prolonged or repeated skin contact with


liquid

TCE

can

cause

irritation

and

dermatitis.

Massive exposure can cause excitation

Kidney

and euphoria, sleepiness and coma.

Altered renal function such as proteinuria


and raised blood urea may occur.

Mucosa Membranes:
Irritation

of

eye,

nose,

throat

and

respiratory tract.

Severe systemic allergic reaction may


occur in sensitive individuals with minimal

Respiratory System:
Chemical pneumonitis and death from

TCE exposure
Note: When there is mixed exposure to

respiratory failure can occur.

perchloroethylene

Heart:
High

Others

exposure

level

can

sensitise

myocardium and cause cardiac arrhythmia

or

and

other

solvents, there may be combined effects


on target organs.
4.0 MEDICAL SURVEILLANCE

and death from cardiac failure.

PRGRAMME
3.2 CHRONIC EFFECTS

Any work where workers are exposed to air


levels of trichloroethylene which are liable

Central Nervous System:


Non-specific complaints like headache,
irritability,

fatigue

and

insomnia.

Psychological disorders. Mood changes,


poor memory impairment in psychomotor
and behavioral tests have been reported.
Alcohol intolerance characterised by skin
vasodilatation especially in the face can
occur.
Neuropathy: loss of function of nerves

to exceed 10% of the permissible exposure


level and/or where there is a risk of skin
contact.
Alcohol intake should be recorded.
4.1 PRE-PLACEMENT MEDICAL
EXAMINATIONS
Clinical examination and baseline data with
emphasis on the:
Central nervous system
Liver

Department of Occupational Safety and Health (DOSH) Malaysia

48

Guidelines On Medical Surveillance

Skin and

trichloroethanol

Kidney

in blood

end-of-shift

urinary

acid

(TCA)

trichloroacetic

determination (results to be corrected


for

specific

gravity

or

urinary

creatinine concentration).
Liver function tests (serum bilirubin,
alkaline

phosphatase,

aspartate

aminotransaminase,
aminotransferase

alanine
and

gamma

glutamyl transferase).

Trichloroethylene in
blood
Trichloroethylene in endexhaled air
Source: TLVs & BEIs ACGIH 2000
4.3

WHERE INDICATED, THE


FOLLOWING TESTS MAY BE
DONE

Workers with liver diseases, solvent abuse

Liver function tests

or who are alcoholics should not work in


areas where there is significant TCE

Note:

exposure.

Workers

4.2

PERIODIC

be

similar

examination.

An

to

pre-placement

annual

check

Workers
chloral

5.0

on

Phenobarbital

hydrate

treatment

and
may

INDICATIONS FOR MEDICAL


REMOVAL PROTECTION

DETERMINANTS
Sampling

from

have increased urinary TCA.

appropriate.

Determinants

abstain

collection

is

BIOLOGICAL EXPOSURE

should

alcohol one week prior to urine

MEDICAL

EXAMINATIONS
Should

end
workweek

INVESTIGATIONS
Mid-week

4mg/L

shift at

BEI

Time

All cases of definite or suspected TCE


poisoning and excessive absorption
of TCE.

Trichloroacetic

End of

100mg/g

acid in urine

workweek

creatinie

Cases with urinary TCA of more than


100

mg/l

in

successive

examination;

Trichloroacetic

End of

acid &

shift at

300mg/g

trichloroethanol

end

creatinine

in urine

workweek

Free

End of

Workers with persistently abnormal


liver function test results.

Department of Occupational Safety and Health (DOSH) Malaysia

49

Guidelines On Medical Surveillance

Workers presenting with fever and skin

Improvement

rash. They should be investigated to

in

work-process

exclude TCE allergy.

Adequate

ventilation,

Approved

Protective

Equipment

*Note:

Personal

Where there is mixed exposure to TCE

Chemical goggles

and perchloroethylene (PCE), a BTLV of

Appropriate signage

50 mg/l should be adopted if the air level


for PCE is less than half PEL. Where the
air level for PCE is more than half PEL, a

8.0
1.

BTL V of 7 mg/l should be adopted.

&

workplace hygiene

REFERENCES
National

Institute

for

Occupational

Safety and Health: Criteria for a


All cases recommended for MRP and

Recommended

Standard.

suspected cases of disease and poisoning

Occupational

must be notified to DG of DOSH.

trichloroethylene. US Department of

6.0 FOLLOW-UP ACTION

(HSM-99-72-129), 1973.

exposure

to

Health, Education and Welfare, USA,

2.

Repeat tests
6.1

50- Trichloroethylene, Geneva 1985.

ABNORMAL RESULTS

If urinary trichloroacetic acid (TCA) level is

3.

Values

excessive

TCE

4.

TCA level fortnightly. The worker may


return to work if urine TCA level falls

5.

Exposure

Hiroka Nakayama; et al: Generalized


With

Severe

Liver

Dysfunctional

Associated

With

Occupational

Exposure

to

R J McCunney: Diverse Manifestations


Of Trichloroethylene. British Journal of
Industrial Medicine, 45, 1988: 122-26.

the worker at increased risk of


exposure to TCE.

Biological

Limit

19; 1988: 48-51.

safe and healthy and does not place


material impairment to health from

Threshold

Trichloroetllylene. Contact Dermatitis,

below 100 mg/l.

work when the workplace hygiene is

and

Eruption

absorption should have a repeat urine

Recommend the worker for return to

of

of

Hygienists:

Indices, Cincinnati, 1999.

RETURN TO WORK
with

Conference
Industrial

Documentation

6.2 MEDICALLY REMOVED WORKER &

cases

American
Governmental

100 mg/l or more, repeat test immediately.

All

WHO: Environmental Health Criteria

6.

Masana
Monitoring

Ogata

et

VII:

al:

Biological

Occupational

Exposures to Mixtures of Industrial


7.0 PREVENTIVE MEASURES
Department of Occupational Safety and Health (DOSH) Malaysia

50

Guidelines On Medical Surveillance

13. n-HEXANE

Chemicals. Appl Occup Environ Hyg,


8(7),1993: 609-17.
7.

Kazunori Sreiju; et al: Dose-Excretion


Relationship in Tetrachloroethylene-

1.0 SYNONYMS: Hexylhydride,

Exposed Workers and the Effect of

skellysolve

Tetrachloroethylene Co-exposure on

Physicochemical properties

Trichloethylene Metabolism. Am J Ind

Colourless flammable liquid, highly volatile

Med 16: 1989:67584.


8.

PEL 8hr TWA : 50 ppm

Phoon WH, Magdalene Chan, Ho SF,


Dept of Industrial Health Guidelines
For Designated Factory Doctors-The
Factories

(Medical

Regulations

9.

Dept

Examinations)
of

Community,

Mechanism of action
Irritant. Depressant for central nervous
Route of Absorption
It is readily absorbed by all routes but in

Occupational and Family medicine

industry

National University of Singapore 1997.

Inhalation & dermal routes dominates.


Readily soluble in fat. About15-20% of

Control of Substances Hazardous to

hexane is taken up by the lungs

Health

(COSHH)

Regulation

11-Health

Regulations:
Surveillance-

Non-occupational exposure

Trichloroetylene in The Health and

N-hexane may be present in glues or other

Safety

household solvent mixtures

Factbook

Health

&

safety

Executive, Professional Publishing Ltd


London, 1989:1/10.

Excretion
50-60% of absorbed dose is exhaled
unchanged, in a biphasic pattern with a
half-life of 14 minutes and 2.5 hours. One
third of absorbed dose is metabolised and
rapidly excreted in the urine.
Metabolism proceeds via methyl butyl
ketone to 2,5-hexanedione, the agent
responsible for the neurotoxic action of
hexane and methyl butyl ketone.
2.0

OCCUPATIONS AT RISK OF
EXPOSURE
Chemical synthesis
Fuel. Lubricant

Department of Occupational Safety and Health (DOSH) Malaysia

51

Guidelines On Medical Surveillance

Solvent in glue used in shoe making

Respiratory system.
Urine

estimation

(early

morning

specimen corrected for creatinine.


3.0 TOXIC EFFECTS
3.1

BIOLOGICAL EXPOSURE

ACUTE EFFECTS

DETERMINANTS

Conjunctivitis, Defatting dermatitis,


Dizziness.
Nervous system- narcosis, dizziness,
Ataxia,
In coordination.
Peripheral neuropathy has been
reported.
Anorexia and nausea, irritation.

Determinants
2,5
Hexanedione
in urine
n-Hexane in
end exhaled
air

Sampling
Time
End of shift
End of shift

BEI
5 mg/g
creatinine
144
mg/m3

Source: TLVs & BEIs ACGIH 2000.


Blood or alveolar air n-hexane and urinary

3.2

CHRONIC EFFECTS
Nervous system-neuropathy,
weakness & loss of sensation at
extremities.

4.0

MEDICAL SURVEILLANCE
PROGRAMME

Any work where workers are exposed to


levels of airborne levels, which are liable to
be in excess of half the -in-air standard,

metbolites all may be used in biological


monitoring .
Urinary 2,5 Hexanedione seems to be most
applicable for routine monitoring, especially
because this metabolite is linked to the
neurotoxic effect of hexane.
An 8 hr exposure to 50 ppm has, in
different studies , resulted in about 2 to 6
mg/L ( 20-50 mol / L of 2,5 Hexanedione
in post-shift.

and or where there is significant risk of

4.2

ingesting it.

EXAMINATIONS

This is directed at the avoidance of

This should have a similar content to the

neuropathy from chronic poisoning

pre-employment examination. A

4.1

appropriate

PERIODIC

MEDICAL

frequency of once or twice a year is


PRE PLACEMENT EXAMINATIONS

Clinical examination and baseline with

Additional elements may include:

particular attention to:

1.

Psychological testing

2.

Testing of nerve function by recording

Kidneys
Neurological and

conduction velocities

Department of Occupational Safety and Health (DOSH) Malaysia

52

Guidelines On Medical Surveillance

5.0 INDICATIONS FOR MEDICAL

Symptomatic and supportive

REMOVAL PROTECTION

Appropriate signage

All cases of definite or suspected


poisoning and excessive absorption.

7.0 PREVENTIVE MEASURES

All cases recommended for MRP and


suspected

cases

of

Adequate ventilation

disease,

Personal Protective equipment

poisoning and excessive absorption

Chemical goggles

must be notified to the DG (DOSH).


6.0

Chemical cartridge respirator


Rubber gloves

FOLLOW-UP ACTION

Prohibited in the cleaning and

Repeat tests.
6.1

degreasing purposes.

ABNORMAL RESULTS

8.0 REFERENCES

If the urine symptoms & signs persist,


a

6.2

repeat

test

must

be

1.

done

Control of Substances Hazardous to


Health

(COSHH)

Regulations:

immediately.

Regulation11-Health Surveillance- n-

MEDICALLY REMOVED WORKER

Hexane in The Health and Safety

& RETURN TO WORK

Factbook Health & safety Executive,


Professional Publishing Ltd London

All suspended cases should have


repeat
relevant

urine

examinations

biochemical

tests

1989:1/11.

(and
where

indicated) at 3-monthly intervals and

2.

Toxicology Heyden 1987: 208-9.

should not return to work until the


signs and symptoms and abnormal
biochemical

results

have

Plukett ER Handbook of Industrial

3.

disappeared.

American

Conference

Governmental

Industrial

of

Hygienist:

Documentation of the Threshold Limit

Recommend the worker for return to

Values

and

Biological

work when the workplace hygiene is

Indices, Cincinnati 2000.

Exposures

safe and healthy and does not place


the worker at increased risk of

4.

Information

on

the

Prohibition

of

material impairment to health from

Substances from Certain purposes.

exposure to hexane.

DOSH, 1999:5.

6.3 TREATMENT
Irrigate eyes with water
Wash contaminated areas of body with
soap and water
Department of Occupational Safety and Health (DOSH) Malaysia

53

Guidelines On Medical Surveillance

1.0 Synonyms: BCME


Physicochemical properties
Colourless, highly volatile liquid with
suffocating odour
TLV 0
Route of entry
Inhalation
Most potent Carcinogen-and is no longer
used in chemical industry in USA.
2.0 OCCUPATIONS AT RISK OF
EXPOSURE TO BCME
Used in Chemical synthesis (as
organic solvent)
Manufacture of ion exchange resin
3.0 TOXIC EFFECTS
3.1

ACUTE EFFECTS

Irritation of eye & respiratory tract


Sore throat, Fever.
3.2

CHRONIC EFFECTS

Cough, chest pains, loss of weight.


Oat cell & small cell carcinoma.
A human and animal Carcinogen
( IARC 1)
4.0

MEDICAL SURVEILLANCE
PROGRAMMME

Any work where workers are exposed to


levels of airborne levels and which are
liable absorbed or where there is significant
14. BIS (CHLOROMETHYL) ETHER

risk of ingesting it.

BCME

Department of Occupational Safety and Health (DOSH) Malaysia

54

Guidelines On Medical Surveillance

4.1 PRE-PLACEMENT MEDICAL

If the CXR, sputum cytology exceeds, a

EXAMINATION

repeat test must be done immediately.

Clinical examination and baseline data with


particular attention to lung cancer

Refer to chest physician.


6.2

MEDICALLY REMOVED WORKER


& RETURN TO

Chest X-rays

WORK

All suspended cases should have


4.2

PERIODIC

MEDICAL

repeat tests

EXAMIANTION

Recommend the worker for return to

Annual examination

work when the

workplace hygiene

is safe and healthy and does not


4.3

WHERE INDICATED, THE

place the worker at increased risk of

FOLLOWING TESTS MAY BE

material impairment to health from

DONE

exposure to BCME.

Full blood count


Sputum cytology
Chest

X-

Ray

7.0
after

years

of

PREVENTIVE MEASURES
Adequate ventilation

exposure

Closed systems
Chemical cartridge respirator, House

5.0

INDICATIONS FOR MEDICAL

keeping, personal cleanliness

REMOVAL PROTECTION

Appropriate signage

All cases of definite or suspected


poisoning and excessive absorption.
All cases recommended for MRP and

8.0

1. Plunkett E R Handbook of Industrial


toxicology, Industrial

suspected cases of poisoning / excessive

Health Services

Barberton, Ohio. 1987: 58-9.

absorption must be notified to the DG


2.

(DOSH).

REFERENCES

Rom MN Environmental and


Occupational Medicine 2

6.0

FOLLOW-UP ACTION

physical

examination

investigations.

Edition .Pg

Little, Brown& Co.


Boston/Toronto/London 1992:

Repeat tests if abnormality is detected in


history,

nd

854,941,1025,1379.

and
3.

Olson KR, Poisoning & Drug overdose


a Lang clinical manual 1999:452.

6.1

ABNORMAL RESULTS

Department of Occupational Safety and Health (DOSH) Malaysia

55

Guidelines On Medical Surveillance

(Including chromate or dichromate of


potassium, sodium, ammonium or zinc
chromic acid)
1. 0 SYNONYMS: Chromic acid, Chromic
Sulphate, Chromium trioxide, Potassium
dichloromate dihydrate.
Physicochemical properties
Hard, silvery-grey metal, compounds are
various colour.
Route of entry
Inhalation
Dermal
Ingestion.
Mode of action
Irritant, Corrosive, Sensitiser.
Hexavalent salts are most toxic
Carcinogenic salts are most toxic.
Carcinogenic factor seems to be related to
the manufacture of dichromates from the
ore (Calcium chromate).
2.0

OCCUPATIONS AT RISK OF
EXPOSURE

Antioxidants, Batteries, Cement, Chrome


plating, pigment (yellow), Refectories, Steel
alloys, welding and wood preservatives.
3.0 TOXIC EFFECTS
3.1 ACUTE EFFECTS
Skin

Sensitising dermatitis,
Chrome hole- skin ulcers

15 & 16. CHROMIUM METAL AND


ITS COMPOUNDS

Eye

Conjunctivitis

Gastro

Anorexia, nausea, hypertrophic

Intestinal

gastritis, Duodenal ulcer, colitis

Department of Occupational Safety and Health (DOSH) Malaysia

56

Guidelines On Medical Surveillance


Determinants

Irritate respiratory tract,

Upper
respiratory
tract

Nasal polyps, Epistaxis,


sinusitis, laryngitis, anosmia
Chest pain, dyspnoea,

Lungs

Pulmonary oedema

Renal

Acute renal tubular necrosis

End of shift or
end of
workweek

30g /g

creatinine

creatinine

Source: TLVs & BEIs ACGIH 2000

Patch test with 0.5% dichromate

Chrome ulcers- deep ulcers

4.1

where chromate are deposited


on the skin sand not washed off.
Bronchitis, chemical

PRE-PLACEMENT MEDICAL
EXAMINATIONS

Clinical examination and baseline data with


particular attention to:

pneumonitis, chromitosis
(pneumoconiosis),

Detect pre-existing allergies

bronchogenic carcinoma of

Lung disease

lung,

Skin diseases ( by means of a

Nasal

septum

perforation.

Usually symptomless

Chrome

10g /g

Chromium in blood and urine

The latent period may be 20years.

Lung

Increase
during shift

Diagnostic criteria / investigation

3.2 CHRONIC EFFECTS

Skin

Chromium (IV)
Water soluble
Fume
Total
Chromium in
urine

BEI

Sampling
time

Perforation of nasal system,

ulcers-

deep

ulcers

questionnaire ),
Urine

specimen

where

Lung cancer (Hexavalent chromium)


0

4.0 MEDICAL SURVEILLANCE


PROGRAMME
Any work where workers are exposed to
levels of airborne levels, which are liable to
be in excess of half the -in-air standard,
and or where there is significant risk of
ingesting it.

(early

corrected

to

morning
creatinine

clearance)

chromates are deposited on the skin sand


not washed off.

estimation

4.2

PERIODIC

MEDICAL

EXAMINATIONS
Annual

examinations

as

at

the

pre-

placement check are appropriate including


looking for nasal septum perforation
4.3

WHERE INDICATED, THE


FOLLOWING TESTS MAY BE
DONE

Annual physical examination of exposed


BIOLOGICAL EXPOSURE

personnel including

DETERMINANTS

Chest x-ray

Department of Occupational Safety and Health (DOSH) Malaysia

57

Guidelines On Medical Surveillance

material impairment to health from

Pulmonary function test, FEV and

exposure to chromium metal and it

FVC.

compounds.

Papanicolaou studies of the sputum at


periodic intervals for those at high risk
jobs.
5.0

6.3

First Aid: All cases of poisoning

INDICATIONS FOR MEDICAL

must be immediately removed from

REMOVAL PROTECTION &

exposure and must be referred for

RETURN TO WORK
All

cases

of

hospital treatment.

definite,

suspected

Irrigate eyes with water.

poisoning and excessive absorption.

Wash contaminated areas of body

(e.g. skin lesions) of chromium or its

with soap and water.

compounds.
All

TREATMENT

cases

Dermatitis: Antihistamines, cortisone

recommended

for

locally

MRP,
and

Skin ulcers: Apply 10% edathamil

excessive absorption must be notified to

calcium disodium in lanolin base to

the DG (DOSH).

ulcer, bandage for 24 hours, curette

suspected

cases

of

poisoning

base and repeated as necessary,


6.0 FOLLOW-UP ACTION

Edathamil calcium disodium has

Annual physical examination of exposed

been suggested, Symptomatic and

personnel including

supportive.

Chest x-ray,
Pulmonary function test: FEV1 and

7.0

PREVENTIVE MEASURES
Adequate

FVC

ventilation,

and

regular

monitoring of the work environment,


6.1

ABNORMAL RESULTS

If the urine level exceeds, a repeat test


must be done immediately.

mechanical filter respirator, chemical


goggles,

rubber

gloves,

aprons,

boots.
No eating or smoking in work area

6.2

MEDICALLY REMOVED WORKER


AND RETURN TO WORK
Must be followed up regularly.

Apply Vaseline or paraffin to nose


before going to work
Appropriate signage

Recommend the worker for return to


work when the

workplace hygiene

8.0 REFERENCES

is safe and healthy and does not

1. Phoon WH, Magdalene Chan, Ho SF,

place the worker at increased risk of

Dept of Industrial Health Guidelines

Department of Occupational Safety and Health (DOSH) Malaysia

58

Guidelines On Medical Surveillance

For Designated
Factories

Factory Doctors-The

(Medical

Regulations

Dept

Tripoli

Examinations)
of

Community,

0.1 mg/m3 of contained


respirable quartz

Physicochemical properties

Occupational and Family medicine

Depends on the content of silica and size

National University of Singapore 1995.

and whether respirable or not.

2. Plunkett E R Handbook of Industrial


toxicology, Industrial Health Services

Route of entry
Inhalation
2.0 OCCUPATIONS AT RISK OF

Barberton, Ohio. 1987: 86-8.

EXPOSURE
3.

International

Labour

Office:

Mining, quarrying and tunneling of

Encyclopaedia of Occupational Health

siliceous rocks (e.g. granite,

and Safety, Geneva, 4th edition, 1998.

sandstone, slate, mica, silica


containing coal or metal ores)

4. American Conference of Governmental


Industrial

Rubber

Hygienist: Documentation

milling

(using

calcium

carbonate containing silica)

of the Threshold Limit Values and

Foundries

Biological Exposures Indices, Cincinnati

fettling)

2000.

Abrasive blasting using siliceous


grains

5. Control of Substances Hazardous to


Health

(COSHH)

Regulation

11-Health

(mould

(e.g.

breaking

sandstone,

&

sand,

quartzite & flint)

Regulations:

Manufacture

Surveillance-

(chinaware, porcelain, earthenware)

of

ceramics

Chromium in The Health and Safety

and refractories

Factbook Health & safety Executive,

Maintenance & repair of refractories

Professional Publishing Ltd London,

(furnace linings);

1989-1/9.

Stone cutting, dressing, polishing,


cleaning & monumental masonry
(including tombstone

17. FREE CRYSTALLINE SILICA


1.0 SYNONYM:

Silicon

engraving)

using granite & sandstone.

dioxide,

cristobalite,

Enameling using quartz, feldspar,

quartz, tryidymite

metal oxides and carbonates

PEL 8hr TWA Silica, Crystalline


Cristabalite 0.05 mg/m3
Quartz
0.05 mg/m3
Tridymite
0.05 mg/m3

Manufacture of abrasive soaps


3.0 TOXIC EFFECTS
3.1

ACUTE EFFECTS

Department of Occupational Safety and Health (DOSH) Malaysia

59

Guidelines On Medical Surveillance

Silicosis - rare
due

to

to exceed 50% of the permissible exposure


inhalation

of

high

concentrations of very fine free silica


dust particles (e.g. manufacture of
abrasive

soaps,

tunnelling

&

sandblasting)
may develop within a few months with
severe dyspnoea, cough, mucoid
sputum,

fever,

weight

loss

level.
4.1 PRE-PLACEMENT MEDICAL
EXAMINATIONS
Clinical examination and baseline data with
particular emphasis on:
Chest and pulmonary function test,
including

&

cyanosis

by 430mm).

Most of the cases are asymptomatic

wheezing

statement

of

the

medical,

occupational and smoking history of

Some may have dyspnoea, cough &

the person examined.


Detailed examination for tuberculosis.

Note:
Silica is silicon dioxide (SiO2); also

Any laboratory or other test for which


in the opinion of OHD.

called "crystalline" silica. Includes


quartz, tridymite and cristobalite

Examination

Silicotics may develop progressive


Silicotics are more prone to developing
pulmonary tuberculosis They may
also have a higher risk of lung
cancer .
There is also an association with
scleroderma

and

chronic

renal

disease

PROGRAMME
(Mineral

the

cases

chest

may

even

reveal

in

little

4.2

PERIODIC

MEDICAL

EXAMINATIONS
Conducted annually. Tests may be the
same as pre-placement but will depend on
the exposure levels and symptoms and
signs of disease and poisoning.
4.3 WHERE INDICATED, THE

MEDICAL SURVEILLANCE
to

advanced

of

abnormality

massive fibrosis

Machinery

vital

chest x-ray (posterior-anterior, 350 mm

Silicosis

refer

forced

Full size chest x-ray examination. A

3.2 CHRONIC EFFECTS

Please

of

volume at one second (FVC1).

fatal within a year

4.0

testing

capacity (FVC) & forced expiratory

FOLLOWING TESTS MAY BE


the

Factories

Dust)

and

Regulations

1989.

DONE:
Lung function test e.g. forced vital

Any work where workers are exposed to

capacity (FVC) and forced expiratory

levels of airborne free silica which are liable

volume in one second (FEV1).

Department of Occupational Safety and Health (DOSH) Malaysia

60

Guidelines On Medical Surveillance

RETURN TO WORK

Sputum examination for acid fast


bacilli.

All suspended silicosis cases should


be followed up annually or more

5.0 INDICATIONS FOR MEDICAL

frequently to exclude complications.

REMOVAL PROTECTION

Recommend the worker for return to


work when the

It is not necessary to suspend all cases

is safe and healthy and does not

with silicosis. The following should be

place the worker at increased risk of

considered for permanent suspension:

material impairment to health from

Cases with definite evidence of


silicosis aged below 35 years and
who are symptomatic (e.g. with
pulmonary

tuberculosis,

chronic

bronchitis or cardiac failure).


Cases with pulmonary tuberculosis
and

other

cardio-respiratory

workplace hygiene

exposure to silica.
Note: *The chest radiographs should be
compared with the set of standard films of
ILO 1980 Classification of Radiographic
appearances

of

the

Pneumoconiosis

(Reference 4)
6.3 TREATMENT

diseases.

There is no definite treatment for

All cases recommended for suspension

silicosis, thus prevention should be

and suspected cases of silicosis must be

emphasized.

notified to the DG (DOSH).

All pulmonary tuberculosis cases


should be referred for further

6.0 FOLLOW-UP ACTION

management in a chest

Repeat tests

hospital/clinic.

6.1 ABNORMAL RESULTS

Symptomatic silicotic cases may

All suspected cases of silicosis (category

require treatment as and when

1/0*) should have a repeat full-size chest x-

indicated.

ray and clinical examination after one year


(or earlier if symptomatic).

7.0

PREVENTIVE MEASURES
As there is no cure for silicosis

Cases of definite silicosis (category 1/1 *


and above, consistent in 2 consecutive

preventive measures are essential.


Workers

should

films) should be followed up annually with a

tuberculosis

full

silicosis.

size

chest

-ray

and

clinical

is

not

smoke,

associated

examination to exclude complications (e.g.

Use approved PPE

pulmonary tuberculosis, chronic bronchitis

Appropriate signage

as
with

and cardiac failure).


6.2

MEDICALLY REMOVED CASES &

8.0 REFERENCES

Department of Occupational Safety and Health (DOSH) Malaysia

61

Guidelines On Medical Surveillance

1.

Factories

and

Machinery

(Mineral

Executive, Professional Publishing Ltd

Dust) Regulations 1989.


2.

National

Institute

for

London, 1989:1/11.
Occupational

8.

Criteria for diagnosis of occupational

Safety and Health: Criteria for a

lung

Recommended

1997:8-9.

Standard.

disease,

Ministry

of

Health

Occupational Exposure to Crystalline


Silica.

US Department of Health,

Education, and Welfare, USA 1974.


(HEW Publication No (NIOSH) 75120).
3.

Vigliani EC: Silicosis In: Encyclopaedia


of Occupational Health and Safety,
International Labour Office: Geneva,
3rd edition 1983: 2037-41.

4.

International Labour Office: ILO U/C


International

Classification

Radiographs

of

of

Pneumoconiosis,

Occupational Safety and Health Series


22 (rev), Geneva, 1980.
5.

World

Health

Organisation:

Pneumoconiosis In: Early detection of


occupational diseases, Geneva, 1986:
9-25.
6.

Davis GS: Silica In: Occupational and


Environmental Respiratory Disease,
Harber P, Schenker MB, Balmes JR,
editors, Mosby-Year Book, 1996: 37399.

7.

Control of Substances Hazardous to


Health

(COSHH)

Regulations:

Regulation11-Health

Surveillance-

Lung

diseases

due

to

dusts:

pneumoconiosis in The Health and


Safety Fact book Health & safety

Department of Occupational Safety and Health (DOSH) Malaysia

62

Guidelines On Medical Surveillance

PEL 8 hr TWA
Methylene bisphenyl isocyanate (MDI)
0.005
ppm
Methyl isocyanate (MIC)

0.02

ppm
Toluene-2, 4-diisocyanate (TDI)

0.005

ppm
Route of absorption
Inhalation
Percutaneous
2.0 OCCUPATIONS AT RISK OF
EXPOSURE
Foam resins
Plastic coatings
Synthetic rubber
Varnishes and lacquers
3.0

TOXIC EFFECTS

Symptoms and signs


Severe irritation of eyes, dehydration
of tissues, and corneal damage.
Irritation of skin and burns; darkening
and
18.

ISOCYANATES

hardening

may

occur

after

repeated exposures. Corrosive.


Angioneurotic

edema.

Irritation

1.0 SYNONYMS:

pharynx.

Dyspnea.

4,4' Diphenylmethane diisocyanate (MDI)

Cough. Chest tightness. Asthma

of

Headache.

Hexamethylene diisocyanate (HDI).


Methyl isocyanate (MIC).

Recognised

by

shortness

I, 5Naphthalene diisocyanate (NDI)

develop at exposure to levels below

Toluene diisocyanate (TDI) and many

those causing irritation.

Physiochemical Properties
Liquids and Solids

breath.

wheeze,

Methylene diisocyante (MDI)

others

of

cough,

This

may

Once sensitisation has developed,


very low levels of exposure will
produce symptoms. Bronchitis.
Pulmonary edema.

Department of Occupational Safety and Health (DOSH) Malaysia

63

Guidelines On Medical Surveillance

Nausea and vomiting

Kidneys
Further tests include:

3.1 ACUTE EFFECTS

1.

Clinical examination of the chest

Irritation, sensitization
Skin & upper respiratory tract toxicity.

2.

Pulmonary function testing- Spirometry

3.

Chest X-ray

Burning of eyes and skin, cough and

Relative contraindications i.e. conditions

wheezing are common.

likely to be regarded as rendering those

Non-cardiogenic pulmonary oedema


may occur.

with them less fit for exposure to


isocyanates are:

Symptoms may occur immediately with


exposure or may occasionally be

Hay

bronchitis,

disease.
Some types of eczema.

CHRONIC EFFECTS

Chronic exposure may cause lung

Poor lung function test ( i.e. man with


FEV1 1 litre or more below normal or

fibrosis and fall in lung function.

recurrent

asthma, chronic pre-existing lung

delayed by several hours.


3.2

fever,

woman with FEV1 0.8 litre or more

Eosinophilia may occur.

below normal.

Disability:

4.2

Sensitization may be permanent.

Respiratory

changes

can

be

PERIODIC MEDICAL

EXAMINATIONS
Tests of lung function at intervals after

permanent.

start of exposure:2 weeks, 6 weeks


4.0

MEDICAL SURVEILLANCE

and 6 months and at 6-monthly

PROGRAMME

intervals thereafter.

There are no specific blood or urine

Physical

examination

of

tests for isocyanates.

personnel annually

Isocyanate antibody testing although useful

X-rays, FEV 1 and FVC.

epidemiologically, is difficult to interpret in


an individual.
4.1 PRE-PLACEMENT EXAMINATIONS
Clinical examination and baseline data with
particular attention to identify those with
pre-existing

disease

and

to

establish

baseline records of fitness. This includes


consultation with the OHD with particular
reference to:
Respiratory systems

5.0

exposed

including chest

INDICATIONS FOR MEDICAL


REMOVAL PROTECTION

All cases of definite or suspected


poisoning and excessive absorption.
All cases recommended for MRP and
suspected cases of poisoning/excessive
absorption must be notified to the DG
(DOSH).
6.0 FOLLOW-UP ACTION

Department of Occupational Safety and Health (DOSH) Malaysia

64

Guidelines On Medical Surveillance

Establish

the

diagnosis,

if

confirmed,

Adequate

suitability to continue the work has to be

ventilation

with

regular

monitoring of work environment

reviewed.

Chemical goggles or face shield

6.1

Chemical cartridge respirator or airline

ABNORMAL RESULTS

If the symptoms & signs persist, a repeat

mask

test must be done immediately.


6.2

Butyl rubber gloves, aprons, and boots


No smoking

MEDICALLY REMOVED WORKER

Appropriate signage.

&
RETURN TO WORK

Preclude

All suspended cases should have


repeat

clinical

relevant

examinations (and

biochemical

tests

where

indicated) at 3-monthly intervals and

from

exposure

those

with

allergies and chronic diseases of skin,


nose, throat and lungs.
Remove from exposure those who become
sensitized to isocyanates.

should not return to work until the


signs and symptoms and abnormal
biochemical

results

have

disappeared.

8.0 REFERENCES
1.

Workers
workplace hygiene

is safe and healthy and does not


place the worker at increased risk of

2.

Peters. J. M. et al: Pulmonary Toxicity


of Isocyanates. Ann. Internal Med. 73:
654,1970.

exposure to isocyanates.
3.

Control of Substances Hazardous to


Health

First Aid
Irrigate eyes with water

Regulation

11-Health

Regulations:
Surveillance-

Factbook Health & safety Executive,

isopropyl alcohol and then with soap

Professional Publishing Ltd London,

and water
Maintain open airways, oxygen, if

(COSHH)

isocyanine in The Health and Safety

Wash contaminated areas of body with

Treat skin burns in the usual manner

Organic

63: 375, 1970.

material impairment to health from

6.3 TREATMENT

Handling

Diisocyanates. Proc. Roy Soc. Med.

Recommend the worker for return to


work when the

Hill. R. N. A Controlled Study of

1989:1/5.
.

required
Bronchodilators,

Symptomatic

and

supportive
7.0

PREVENTIVE MEASURES

Department of Occupational Safety and Health (DOSH) Malaysia

65

Guidelines On Medical Surveillance

Chemical

element:

heavy

gray,

soft,

malleable metal.
2.0

OCCUPATIONS AT RISK OF
EXPOSURE
Manufacture

of

lead-acid

storage

batteries (accumulators)
Manufacture and use of stabilizers in
PVC compounding
Burning/welding/cutting of lead-coated
structures e.g. ship-breakers and
welders
Manufacture and use of ammunition
e.g. firing range instructors
Manufacture and use of lead-based
paints & solder
Manufacture and use of glazes for
porcelain, enamels, tiles
Manufacture of alloys
3.0 TOXIC EFFECTS
19. LEAD

Hematological:

( INCLUDING ORGANIC LEAD


COMPOUNDS)

Anemia, or a falling hemoglobin level;


pallor and fatigability may be present.
Gastrointestinal:

19.1 INORGANIC LEAD


1.0 SYNONYMS: Plumbum, Glover
PEL 8hr TWA:
Lead elemental, and inorganic cpds
0.05mg/m3
Lead arsenate as Pb3 (AsO4) 2
0.15 mg/m3
Lead chromate as Pb

0.05 mg/m3

as Cr

0.012 mg/m3

PHYSICOCHEMICAL PROPERTIES

Mild -anorexia, epigastric discomfort,


constipation or diarrhea
Severe -abdominal colic
(Burton's

line,

bluish-black

pigmentation at margins of gums, is an


indication of lead exposure, not of lead
poisoning)
Peripheral nervous system:
Paresis

(rarely

paralysis),

often

affecting extensors of the hand or foot,


with no sensory changes.

Department of Occupational Safety and Health (DOSH) Malaysia

66

Guidelines On Medical Surveillance

4.1 PRE-PLACEMENT MEDICAL

Central nervous system:


Encephalopathy
severe

may

poisoning

occur

with

(drowsiness,

convulsions, coma)

EXAMIANTION
Clinical examination and baseline data with
particular emphasis on:
Hemoglobin

Slow mental changes may occur

(g/dL)

the

hematological and Blood lead level

(learning difficulty, behavioral changes

(venous

etc have been described in children

container)

with lead-exposure)

level
blood

in

heparinised

Nervous systems
Where lead poisoning is suspected the

Renal:
Chronic

nephritis

and

tubular

following tests may be done:


Urinary lead (pre-and-post chelation)

degeneration may occur

Urinary coproporphyrin

Reproductive:

Electromyograph

Lead can cross the placenta and may


cause neurological damage to the
foetus (abortion, stillbirths).

4.2

PERIODIC

MEDICAL

EXAMIANTION
(Every 6 monthly)

4.0 MEDICAL SURVEILLANCE

1. Blood test for lead level

PROGRAMME

2. Other relevant biological tests as

Any work where workers are exposed to

indicated

levels of airborne lead (e.g. dust, fumes)


which are liable to exceed 10% of the

5.0 INDICATIONS FOR MEDICAL

permissible exposure level, and/or where

REMOVAL PROTECTION

there is a significant risk of ingesting lead


(e.g. handling of lead powders, paste, etc).
BIOLOGICAL EXPOSURE
DETERMINANTS

According to the Factories & Machinery


(Lead) Regulations 1984:
Removal is carried out under the following
conditions

Determinants

Sampling
time

BEI

Lead in blood

Not critical

30 g / 100 ml

Lead in urine

Not critical

150 g /g
creatinine

Periodic

and

follow

up

blood

sampling test are at or above 80


gm/100ml of whole blood.
The average of the last 3 blood
sampling tests conducted indicates

Source: TLVs & BEIs ACGIH 2000

that the employees blood level is at


or > 73gm/100ml of whole blood.

Department of Occupational Safety and Health (DOSH) Malaysia

67

Guidelines On Medical Surveillance

Periodic

and

follow

up

blood

Note: Each laboratory has its own "normal

sampling test of a females employees

range"

of child- bearing capacity indicate that

levels below the lower limit of this range

the employees blood level is at or

may be taken as anaemia).

above 40 gm/100ml of whole blood.


The

result

of

haemoglobin.

Haemoglobin

All pregnant or breastfeeding mothers.

finding,

All cases recommended for suspension

determination or opinion shows that

and suspected cases of lead poisoning

employee

must be notified to the DG (DOSH)

has

medical

for

detected

medical

condition which increased risk of


material impairment to health from
exposure to lead.
A pregnant employee and breast
feeding employee from work, which

6.0 FOLLOW-UP ACTION


Repeat Tests.
6.1 ABNORMAL RESULTS:

may expose the said employee to

Repeat

lead.

all

abnormal

results

immediately.
If the repeat result is still abnormal,

However, for GOOD OCCUPATIONAL

refer to the table below.

HEALTH PRACTICES THE FOLLOWING


SUGGESTIONS

SHOULD

A rising blood lead level and/or a

BE

falling haemoglobin level in

FOLLOWED:
All cases of definite or suspected lead

where the blood lead level is

50

g/l00

be

All cases with blood lead levels as


follows:

or

Blood
lead
(mcg/l00

SEX

AGE

Lead levels

Males

All ages

50 g/l00 mI or more

Females

> 50 yrs

50 g/l00 mI or more

Females

< 50 yrs

30 g/l00 mI or more

more

should

significant

Normal

Mild
anaemia

Significant
anaemia

Males (all
ages) and
females >
50 yrs

anemia:

Haemoglobin levels of 10 g/dL or

Haemoglobin

mI)

< 50

of

mI

investigated to exclude poisoning.

poisoning.

Cases

cases

>50*

less for females and 11.0 g/ dL or

No

Review

Action
Suspend +
Notify

Suspend

Suspen

Sus-

d+

pend +

Notify

Notify

less for males confirmed by an


immediate repeat examination
Department of Occupational Safety and Health (DOSH) Malaysia

68

Guidelines On Medical Surveillance


Female <

For an employee of child bearing

50 yrs

capacity,

< 30

> 30**

Source:

No action

Review

Suspend +

Suspend

Notify

+ Notify

Guidelines

for

when

two

consecutive

Sus-

blood sampling tests indicate that

pend

the employees blood level is at or <

Sus-

40 gm/100ml of whole blood.

pend +

An

Notify

employee

removed

subsequent

final

when

medical

determination results in a medical

Designated

finding, determination, or opinion

Factories Doctor, Singapore.

that the employee no longer has

Review:

detected medical condition which

Investigate cause of anemia.

places the employee at increases

Repeat hemoglobin level in 3 months

risk of material impairment to health

Suspended cases

from exposure to lead.

Inform the DG (DOSH), the management

Recommend the worker for return to

and the worker using the Certificate of

work when the

Medical Removal Protection.

is safe and healthy and does not

workplace hygiene

Follow-up at monthly intervals.

place the worker at increased risk of

Investigate the cause of the anaemia

material impairment to health from

and/ or the high blood lead levels.

exposure to lead.

Notify: Notify the DG (DOSH)

All suspended cases should have repeat

*May return to lead work if level is below 40

blood lead examinations (and relevant

g/l00 mI

biochemical tests where indicated) at

**May return to lead work if level is below


Note: g/100 mI

25
6.2

MEDICALLY REMOVED WORKERS


AND RETURN TO WORK

According to the FM (Lead) Regulations


1984
Return to work is carried out under the
following conditions:

monthly intervals. They should not return to


lead work until the blood lead level has
fallen to below the return levels (see
above), all other biochemical results have
returned to normal and any related signs
and symptoms have disappeared.
6.3

TREATMENT

All cases of lead poisoning must be

Two consecutive blood sampling tests

immediately removed from exposure and

indicates that employee blood level

referred for hospital treatment. Chelation

is at or < 60 gm/100ml of whole

therapy with infusion of versenate and/or

blood.

oral penicillamine may be instituted.

Department of Occupational Safety and Health (DOSH) Malaysia

69

Guidelines On Medical Surveillance

7.0

PREVENTIVE MEASURES

8.

Phoon WH, Lee HS, Ho CK: Biological


Monitoring of workers exposed to

Improvement in work process

inorganic

Work-place hygiene
9.

Appropriate signage

1.

Factories

American

Conference
Industrial

values

and

Machinery

(Lead)

Regulations, 1984.
2.

Singapore.

Governmental
Documentation

8.0 REFERENCES

in

Singapore Med J 1990; 31: 127-30.

Use of approved Personal Protective


Equipment

lead

and

of

of

Hygienist:

threshold

biological

limit

exposure

indices, Cincinnati, 1999: BEI-99.


10. National Board of Occupational Safety

Health & Safety Executive: Control of


lead at work -approved code of

and Health: Ordinance AFS Sweden.


1992: 17.

practice. UK, 1981.


3.

Federal

Register:

Occupational

exposure to lead -final standard;


USA 1978.
4.

WHO: Recommended health-based


limit in occupational exposure to
heavy

metals;

Technical

Report

Series 647, 1980; 74-6.


5.

WHO: Diseases caused by lead and


its

toxic

compounds.

In:

Early

detection of occupational diseases.


Geneva, 1986: 85-90.
6.

Barry PSI: Lead: Occupational and


environmental exposure. In: Gardner
A W, ed. Current approaches to
occupational medicine. Bristol, UK,
1979: 1-17.

7.

Zielhuis

RL:

inorganic

Lead:

Alloys

compounds.

and
In:

Encyclopaedia of Occupational health


and

safety.

International

Labour

Office, Geneva, 1983: 1200-4.

Department of Occupational Safety and Health (DOSH) Malaysia

70

Guidelines On Medical Surveillance

be in exceed 50% of the permissible


exposure level, and/or where there is risk
of skin contact with lead alkyls.
4.1 PRE-PLACEMENT MEDICAL
EXAMINATION
Clinical

examination and history, with

particular emphasis on the:


CNS
Estimation

of

urinary

lead

19.2 ORGANIC LEAD (TEL, TML)

concentration in an early morning

1.0

SYNONYMS: Plumbum

urine specimen collected at the end

2.0

OCCUPATIONS AT RISK OF

of the workweek.

EXPOSURE TO ORGANIC LEAD

*Note: i) More frequent tests may be done

Cleaning of tanks containing leaded

depending on exposure.

gasoline or aviation fuel

ii) The tests need only be done before

Production and transportation of antiknock

agents

(organic

and

lead

gasoline at refineries of anti-knock


agents
3.0 TOXIC EFFECTS
Mainly on the central nervous system
(usually acute)
Mild:

the

job

in

case

of

intermittent exposures e g tank

compounds)
Blending anti-knock fluid and raw

after

cleaning
4.2

WHERE INDICATED THE


FOLLOWING MAY BE DONE:

Blood

lead

level

(lipid-extractable

phase of blood sample) - collect in


lithium heparinised tube.
Electroencephalography (EEG)

Headache, tremor, nervousness,

agitation, insomnia, troubled dreams


Severe: Hallucinations, mental confusion,
coma, and death
(Note: In addition to the inhalation route,
organic lead may be absorbed through the
skin)
4.0 MEDICAL SURVEILANCE
PROGRAMME
Any work where workers are exposed to

5.0 INDICATIONS

FOR

MEDICAL

REMOVAL PROTECTION
All cases of definite or suspected lead
poisoning and excessive absorption.
Cases with urine lead of more than
150

g/litre

in

successive

examinations.
All cases recommended for MRP and
suspected

cases

of

lead

levels of airborne lead which are liable to


Department of Occupational Safety and Health (DOSH) Malaysia

71

Guidelines On Medical Surveillance

poisoning/excessive absorption must be

4.

notified to the DG (DOSH).

World

Health

Organisation:

Recommended health-based limit in


occupational

6.0 FOLLOW-UP ACTION

exposure

to

heavy

metals; Technical Report Series 647,

Repeat tests.

1980.

6.1 ABNORMAL RESULTS

5.

Philippe Grandjean: Biological effects

If the urine lead is 150 g/litre or more,

of

repeat test

Press, 1984.

organolead

compounds.

CRC

Immediately.
6.2 MEDICALLY REMOVED CASES &
RETURN TO WORK
All suspended cases should have repeat
urine

lead

examinations

at

monthly

intervals and should not return to lead work


until the urine lead level falls below 150
g/litre and symptoms have disappeared.
6.3 TREATMENT
Treatment with chelating agents does not
appear

to

be

useful

for organo-lead

poisoning. Symptomatic and supportive


treatment is indicated. Several weeks to
years may be necessary for recovery,
which may not be complete.
7.0

PREVENTIVE MEASURES
As for inorganic lead

8.0 REFERENCES
1.

Factories

and

Machinery

(Lead)

Regulations, 1984.
2.

Health and Safety Executive: Control


of lead at work-approved code of
practice. UK, 1981.

3.

Federal

Register:

Occupational

exposure to lead -final standard: USA


1978.

Department of Occupational Safety and Health (DOSH) Malaysia

72

Guidelines On Medical Surveillance

Manufacture of dry-cell batteries


(manganese dioxide)
Iron and steel industry as a reagent
to reduce sculpture and oxygen
Manganese electroplating
Manufacture of paints, varnishes,
inks and dyes, fertilisers, feed
Additives, disinfectants and
bleaching agents, glass and
ceramics (decoloriser and coloring
agent)
20.

MANGANESE

Manufacture of matches and


fireworks

1.0 SYNONYMS:
Potassium

Manganese

Dioxide,

Manufacture of potassium

Permanganate, Pyrolusite

permanganate

PEL 8hr TWA


Manganese, elemental & inorganic cpds as

Welding operations with manganese

Mn

coated rods

0.2mg/m3

Water treatment

Manganese cyclopentadienyl tricarbonyl


0.1mg/
m3
Physicochemical properties
Reddish or steel grey metal, chemical
element, compound in many colours.

3.0

TOXIC EFFECTS

3.1

ACUTE EFFECTS

Manganese dust & fumes cause minor


irritation to the eyes & mucous
membranes of the respiratory tract.

Route of entry

Fume inhalation may result in metal

Inhalation, dermal, ingestion.

fume fever. Manganese dust is not

Manganese salts are strong irritants


Manganese salts produce chronic disease
CNS lesions occur in frontal lobes and
basal
ganglia.
2.0

OCCUPATIONS AT RISK OF
EXPOSURE
Milling of manganese ore

believed to be a causative factor in


pneumonia. If at all, it is only an
aggravating factor to a pre- existing
condition.
Manganese salts (higher valency) caustic effects Symptoms: Papuloerythematous dermatitis, metal fumes
fever, bronchitis and pneumonitis.

Department of Occupational Safety and Health (DOSH) Malaysia

73

Guidelines On Medical Surveillance

Other acute effects Papuloerythematous

State III:

dermatitis, metal fumes fever, bronchitis

Muscular

and pneumonitis

deep tendon reflexes, paralysis of


Spastic in-cordination of

Manganese (bivalent) compounds

gait with propulsion and

cause damage to the central nervous

retropulsion.

system and lungs.


Central nervous system: 3 phases:

4.0 MEDICAL SURVEILLANCE

Sub-clinical stage with vague

PROGRAMME

symptoms

Any work where workers are exposed to

Early clinical stage with acute


psychomotor disturbances, speech
and gait disturbances, tremors, loss
of memory, flat affect

increase

lower extremities.

3.2 CHRONIC EFFECTS

hypertonia,

levels of airborne levels, which are liable to


be in excess of half the -in-air standard,
and or where there is significant risk of
absorbing it.

Fully developed stage with manic

Diagnostic criteria
Elevated content of manganese in

depressive psychosis and


parkinsonism.

blood and urine, but disease may

Lungs: Increased incidence of


pneumonia, acute and chronic bronchitis.

exist without such elevations


Gold curve of spinal fluid shows slight

CHRONIC EFFECTS are also classified


as follows:

rise at mid-zone.
Albumin

CNS: 1 -2 years exposure

may

be

increased

and

manganese may be present.

State I:

Health Safety Executive (UK) Guidelines


Asthenia and apathy, nervousness,

for Exposure

headache, Anorexia, Pains in lower

Blood 7.1-10.4 mg/L

extremities,Somnolence,Impotence

Urine 19 ng/L

4.1

State II:
Slow

PRE-PLACEMENT MEDICAL
EXAMINATIONS

monotonous

speech

with

Clinical examination and baseline data with

stammering, mask like faecies.

particular attention to:

Muscular incoordination, tremors,

Behavioural and

cogwheel phenomena, emotional


disturbances,

gross

rhythmical

movement of arms, legs, trunk


and head.

Neurological changes (speech and


emotional disturbances, hypersonic,
tremor, equilibrium, gait, handwriting
& adiadochokinesis )

Department of Occupational Safety and Health (DOSH) Malaysia

74

Guidelines On Medical Surveillance

Urine manganese estimation (early

6.2 MEDICALLY REMOVED WORKER &


RETURN TO WORK

morning specimen corrected for

creatinine)

All suspended cases should have

Preclude from exposure those individuals

repeat

with disease of liver, kidneys and central

relevant

nervous system or alcoholism.

indicated) at 3-monthly intervals and

4.2

PERIODIC

where

results have disappeared.

Recommend the worker for return to


work when the

workplace hygiene is

FOLLOWING TESTS MAY BE

safe and healthy and does not place

DONE:

the worker at increased risk of material

Blood manganese estimation (venous

impairment to health from exposure to

sample in heparinised container)


Full blood count (including Total White
and differential count)

manganese.
6.3 TREATMENT
Supportive, Irrigate eyes with water

Liver and kidney function


5.0 INDICATIONS

FOR

Wash contaminated areas of body with


soap and water

MEDICAL

Gastric larvage, if ingested, followed

REMOVAL PROTECTION

by saline catharsis

All cases of definite or suspected

Oxygen and artificial respiration

poisoning and excessive absorption.

Supportive measures
Refer to hospital

No BEI values available however the HSE


guidelines may be used.
All cases recommended for suspension
and

tests

symptoms and abnormal biochemical

Tests are conducted annually as for pre-

WHERE INDICATED, THE

biochemical

(and

/ blood level falls below normal levels,

EXAMNIATIONS

4.3

examinations

should not return to work until the urine

MEDICAL

placement

urine

suspected

cases

of

poisoning

7.0

PREVENTIVE MEASURES

Adequate ventilation, Chemical goggles,

excessive absorption must be notified to

Chemical cartridge respirator, polyvinyl

the DG (DOSH).

gloves. appropriate signs.

6.0 FOLLOW-UP ACTION


Repeat tests
6.1 ABNORMAL RESULTS
If the urine or blood level exceeds, a repeat
test must be done immediately.

8.0 REFERENCES
1. Phoon WH, Magdalene Chan, Ho SF,
Dept of Industrial Health Guidelines
For Designated Factory Doctors-The
Factories

Department of Occupational Safety and Health (DOSH) Malaysia

(Medical

Examinations)

75

Guidelines On Medical Surveillance

Regulations

Dept

of

Community,

Occupational and Family medicine


National University of Singapore 1995.
2.

Plunkett E R Handbook of Industrial


toxicology, Industrial Health Services
Barberton, Ohio. 1987: 86-8.

3.

International

Labour

Office:

Encyclopaedia of Occupational Health


and Safety, Geneva, 4th edition, 1998.
4.

Control of Substances Hazardous to


Health

(COSHH)

Regulations:

Regulation11-Health

Surveillance-

Manganese The Health and Safety


Factbook Health & safety Executive,
Professional Publishing Ltd London,
1989:1/8.

Department of Occupational Safety and Health (DOSH) Malaysia

76

Guidelines On Medical Surveillance

2.0

21.

OCCUPATIONS AT RISK OF
EXPOSURE
A. INORGANIC MERCURY
Electrolytic production of sodium

MERCURY

hydroxide, chlorine, & acetic acid


(as fluid cathode)

1.0 SYNONYMS: quick silver, mercuric

Manufacture of scientific

arsenate, chloride, phosphate, thiocyanate


PEL 8hr TWA:
Mercury as Hg
Alkyl compounds

instruments, electrical equipment,


mercury vapour & incandescent
lamps, X-ray tubes, radiovalves and

0.01

artificial silk

mg/m3
Aryl compounds

Dentistry & Taxidermy

0.1

mg/m3

Manufacture of amalgams (with

Inorganic forms, including

copper, tin, silver, gold) and solders

metallic Hg

(with lead & tin)

0.025

Plating of gold, bronze, silver & tin

mg/m3

(jewelers)

PHYSICOCHEMICAL PROPERTIES:

Paint and pigment manufacture

Silvery liquid Metallic Hg evaporates at

Tanning & dyeing, felting

room temperature.

Used as a catalyst in the chemical

Absorption Mercury enters the body mainly


through the lungs as vapour or dust. About
80% of inhaled Hg is absorbed. Some
organic and inorganic Hg (II) compounds
may be absorbed through the skin. The daily
intake of Hg with food is in the range of a
few micrograms.
Biotransformation Absorbed elemental Hg is
quickly oxidised to the Hg 2+ ion, which has
an affinity with sulhydryl (-SH) groups, and
is concentrated in the kidneys (bound to
metallothionein) and liver. Hg is able to pass
through the blood-brain barrier and placenta.
Hg accumulates in the kidneys, liver,
spleen and bones. Metallic Hg is lipid

industry e.g. production of acetic


acid & acetaldehyde from acetylene
Photography & photogravure
Mining & extraction of gold and
silver from ores
Laboratories-soil testing (Hg used a
pressure medium)
Brewery (malt analysis for protein
content)
2.0

TOXIC EFFECTS

soluble and is transported through

A. INORGANIC AND ELEMENTAL

membranes without hinderance.

MERCURY

Excretion Elemental Hg and its inorganic


compounds are eliminated in the urine and
organic compounds in the feces (up to 90%).
The biological half-life of inorganic Hg is
about 6 weeks.

3.1

ACUTE EFFECT INORGANIC AND


ELEMENTAL MERCURY

Chemical pneumonitis -chest pain,


dyspnea, cough

Department of Occupational Safety and Health (DOSH) Malaysia

77

Guidelines On Medical Surveillance

ACUTE E EFFECTS B. ORGANIC

Gastrointestinal tract irritation

3.1

Circulatory collapse

MERCURY

Acute renal failure

Irritation of the mucous membranes

3.2 CHRONIC EFFECT INORGANIC

Chemical pneumonitis
Poisoning (may be acute or chronic)

AND ELEMENTAL MERCURY

Weight loss, Insomnia

Neurological symptoms e.g.

Erythrism

paresthaesia, concentric constrictions

Tremor

of the visual fields,

Dysarthria

Impairment of hearing, rigidity,


tremor, ataxia, chronic seizures

Mercurialentis
Gingivitis, Stomatitis

Fatigue, dyspnoea, chest & abdominal

Excessive salivation

pain, vomiting

Metallic taste

Symptoms of inorganic poisoning may

B. ORGANIC MERCURY
(Alkyl compounds e.g. methyl mercury and
aryl
Compounds e.g. phenyl mercury acetate)
2.0 OCCUPATIONS AT RISK OF

Dermatitis
Prenatal intoxication may occur
resulting in fetal brain damage
Note: Elemental Mercury volatizes at room

EXPOURE

temperature. Mercury and some of its

B. ORGANIC MERCURY

compounds can. be absorbed through

Manufacture & use of certain

intact skin

pharmaceuticals of products (e.g.


antiseptics, germicides, diuretic and
contraceptives)
Manufacture & use of pesticides
(algaecides, fungicides, herbicides)
Manufacture & use of paints &
waxes
(E.g.

be present including renal damage

antifouling

paints,

preservatives in paints, latex paints,

4.0 MEDICAL SURVEILLANCE


PROGRAMME
Any work where workers are exposed to
levels of airborne mercury which are liable
to be in excess of 10% of the permissible
exposure level and/ or where there is
significant

Used as catalyst and alkylating


agents in the chemical industry

of

ingesting

it.

Skin

absorption may be relevant.


BIOLOGICAL EXPOSURE

fungus proofing of fabrics, paper,


wood)

risk

DETERMINANTS
Determinants
Total inorganic
mercury in

Department of Occupational Safety and Health (DOSH) Malaysia

Sampling
Time
Preshift

BEI
35g/g
creatinine

78

Guidelines On Medical Surveillance

urine
Total inorganic
mercury in
blood

creatinine

5.0

End of shift
at end of
workweek

15 g/L

All cases of definite or suspected


poisoning & disease and excessive
absorption. (i.e. urine Hg 35 g/g

Source: TLVs & BEIs ACGIH 2000


Exposure to Hg may be monitored from
concentrations of Hg in blood and urine.
4.1

creatinine)
All cases recommended for MRP and
suspected cases of poisoning / excessive

PRE-PLACEMENT MEDICAL

absorption must be notified to the DG

EXAMINATIONS

(DOSH).

Clinical examination & baseline data with


particular attention to:
Symptoms of weight loss, insomnia &
personality changes and the
Central nervous system, including

6.0

FOLLOW-UP ACTION

6.1

ABNORMAL RESULTS

If abnormal urine Hg level exceeds 35 g/g


creatinine a repeat test must be done
immediately, symptoms & signs persist; a

tremors.

INDICATIONS FOR MEDICAL


REMOVAL PROTECTION

Skin for dermatitis or burns in case

repeat test must be done immediately.

of organic mercury.

6.2

Urinary mercury (total Hg) estimation

& RETURN TO WORK

early morning specimen corrected

All suspended cases should have

for creatinine. Ensure worker avoids

repeat urine Hg at monthly intervals

seafood for 3 days prior to urine

should not return to work until the

collection.
4.2

MEDICALLY REMOVED WORKER

Urine Hg levels falls below 35 g/g


PERIODIC

MEDICAL

creatinine and signs and symptoms

EXAMINATION

have disappeared.

Annually, as for Pre-employment, annually,

Recommend the worker for return to

but if exposure is high more frequently.

work when the

4.3 WHERE INDICATED, THE

is safe and healthy and does not

workplace hygiene

FOLLOWING TESTS MAY BE

place the worker at increased risk of

DONE

material impairment to health from


exposure to mercury.

Urine for albumin and microscopic


examination
Renal function tests, serum albumin/
globulin
Blood total Hg for workers exposed to
alkyl Hg

6.3

TREATMENT

All cases of poisoning must be immediately


removed from exposure and referred for
hospital treatment. Wash contaminated
areas of body with soap and water.

Department of Occupational Safety and Health (DOSH) Malaysia

79

Guidelines On Medical Surveillance

Chelation in the early stages e.g. Calcium

Health and Safety, Geneva, 4 th.

EDTA; oral L-dopa reduces hypertonia,

edition, 1988.

contractions and speech disturbances.


5.
7.0

PREVENTIVE MEASURES

World

Health

Recommended

Organisation.
Health-based

Women in the reproductive age should

Limits in Occupational Exposure to

not work in areas where there is

Heavy Metals - Report of a WHO

significant

Study Group, Technical Report

Hg

exposure

(particularly alkyl Hg)


Improvement

in

Adequate

Series 647, 1980.

work

process,

ventilation,

Personal

Protective

Chemical

Use

of

6.

equipment,

goggles,

Linch A L : Biological Monitoring for


Industrial

medical

Chemical

Exposure

Control, CRC Press, Florida, 1980.

surveillance
Appropriate signage
8.0
1.

7.

Safety and Health : Criteria for a

REFERENCES

Recommended Standard. . . .

Phoon WH, Magdalene Chan, Ho SF,

Occupational

For Designated Factory Doctors-The

of Health, Education and Welfare,

Factories

USA 1973 (HSM-73-11024).

National

(Medical
Dept

Examinations)
of

Community,

University

of

8.

Singapore

CRC

Press,

Cleveland, 1976.

World Health Organisation; Early

9.

Conference

Group,

Governmental Industrial Hygienist :


Values

Exposures

and

Indices

Biological
,

Cincinnati

1999.

Organisation

metals - Report of a WHO Study

of

Documentation of the Threshold

Health

in occupational exposure to heavy

Geneva , 1986: 79-84.


American

World

Recommended Health-based Limits

detection of occupational diseases

Limit

Friberg L & Vostal J: Mercury in the


Environment,

1997.

4.

to

Inorganic Mercury . us Department

Occupational and Family medicine

3.

Exposure

Dept of Industrial Health Guidelines

Regulations

2.

National Institute for Occupational

Technical

Report

Series

647,1980: 102-115.
10.

National Institute of Occupational


Safety

and

Health/Occupational

Safety and Health Administration:


Occupational Health Guidelines for

International

Labour

Encyclopaedia

of

Office:

Chemical Hazards 1981: Vo12.

Occupational

Department of Occupational Safety and Health (DOSH) Malaysia

80

Guidelines On Medical Surveillance

22.

MINERAL OIL INCLUDING


PARAFFIN

1.0 SYNONYMS: Coolant


PHYSICOCHEMICAL PROPERTIES
Petroleum derivatives
Route of absorption
Department of Occupational Safety and Health (DOSH) Malaysia

81

Guidelines On Medical Surveillance

Inhalation, dermal
Mode of action
Irritant.

Chest X-ray may show increased


linear striations
Kidneys

Carcinogenicity due to carcinogenic

Neurological and

aromatic hydrocarbon and contamination

Respiratory system

with nitrosoamines
2.0 OCCUPATIONS AT RISK OF
EXPOSURE
Cutting/ lubricating oils/ fluids.

4.2

PERIODIC MEDICAL

EXAMINATIONS
This has to be done yearly as for preplacement.
5.0

3.0 TOXIC EFFECTS

INDICATIONS FOR MEDICAL


REMOVAL PROTECTION

Skin irritation

All cases of definite or suspected

Oil acne-usually occurs in areas

poisoning and excessive absorption.

contaminated by oil.
Epitheliomata of scrotum (scrotal

suspected cases of poisoning excessive

cancer) have been reported after

absorption must be notified to the DG

many years of exposure.

(DOSH).

Possibility of respiratory, bladder and


gastrointestinal cancer has been
suggested
4.0

All cases recommended for MRP and

6.0

FOLLOW-UP ACTION

6.1

ABNORMAL RESULTS

If the symptoms & signs persist, a repeat

MEDICAL SURVEILLANCE

test must be done immediately.

PROGRAMME

6.2

MEDICALLY REMOVED WORKER

Any work where workers are exposed to

& RETURN TO WORK

levels of airborne levels which are liable to

All suspended cases should have

be in excess of half the -in-air standard and

repeat

or where there is significant risk of

relevant

ingesting it.

indicated) at 3-monthly intervals and

urine

examinations

biochemical

tests

(and
where

should not return to work until the


signs and symptoms and abnormal
biochemical
4.1

PRE-PLACEMENT MEDICAL
EXAMINATIONS

Clinical examination and baseline data with


particular attention to:
Skin diseases

results

have

disappeared.
Recommend the worker for return to
work when the workplace hygiene is
safe and healthy and does not place
the worker at increased risk of

Department of Occupational Safety and Health (DOSH) Malaysia

82

Guidelines On Medical Surveillance

material impairment to health from


exposure to mineral oil including
paraffin.
6.3 TREATMENT
Symptomatic and supportive
All

cases

of

poisoning

must

be

immediately removed from exposure


and referred for hospital treatment.
Irrigate eyes with water
Wash contaminated areas of body with
soap and water
7.0 PREVENTIVE MEASURES
Adequate

ventilation.

Mechanical

filter

respirator. Encourage personal hygiene.


Protective clothing. Educate employees to
report all early skin lesions. Barrier creams.
Appropriate signage.
8.0 REFERENCES
Waterhouse, J. A. H. Lung Cancer And
Gastrointestinal Cancer In Mineral Oil
Workers," Ann. Occup. Hyg. 15:43, 1972.

23. b-NAPHTHYLAMINE
1. 0 SYNONYMS: 2 Aminonapthalene, 2
naphthylamine
PHYSICOCHEMICAL PROPERTIES
Colourless crystals which darken in air to a
reddish purple colour.

It is an aromatic

amine.
PEL 8 hr TWA : 0

Department of Occupational Safety and Health (DOSH) Malaysia

83

Guidelines On Medical Surveillance

Route of entry

Clinical examination & baseline data with

Dermal-well absorbed through skin

particular attention to:

Inhalation

Skin

Ingestion.

Liver, haematopoietic (blood forming)

Mode of action: Carcinogen, local &


systemic toxicity.

Urine cytology

EXPOSURE

Urine estimation (early morning specimen

Chemical synthesis

corrected for creatinine)

Dyes

4.2 PERIODIC MEDICAL EXAMIANTION

3.0 TOXIC EFFECTS

As for pre-placement but done annually.

3.1 ACUTE EFFECTS


over

exposure

Respiratory systems
Urinary tract

2.0 OCCUPATIONS AT RISK OF

Acute

&

can

cause

4.3

WHERE

INDICATED,

methmoglobinemia

FOLLOWING TESTS

Acute Haemorrhagic cystitis

DONE
Urine Cytology if high exposure every

Dysuria
cystitis,

MAY BE

Blood, Full blood count.

3.2 CHRONIC EFFECTS


Haemorrhagic

THE

6 months.

hematuria,

Bladder cancer

5.0 INDICATIONS FOR MEDICAL


REMOVAL

Known Human Bladder carcinogen


(IARC A1)

All cases of definite or suspected


poisoning and excessive absorption.

Dermatitis
Ataxia

All cases recommended for MRP and

Methemoglobinemia

suspected cases of poisoning / excessive


absorption must be notified to the DG
(DOSH).

4.0 MEDICAL SURVEILLANCE


PROGRAMME
Any work where workers are exposed to
levels of airborne levels which are liable to
be in excess of half the-in-air standard and
or where there is significant risk of
absorption, ingesting inhalation.
4.1 4.1 PRE-EMPLOYMENT MEDICAL

6.0 FOLLOW-UP ACTION Repeat tests


6.1

ABNORMAL RESULTS:

If the investigations, symptoms

& signs

persist, a repeat test must be done


immediately.
6.2

MEDICALLY REMOVED WORKER


& RETURN TO WORK

EXAMINATION
Department of Occupational Safety and Health (DOSH) Malaysia

84

Guidelines On Medical Surveillance

All suspended cases should have


repeat

urine

relevant

examinations

biochemical

tests

(and
where

indicated) at 3-monthly intervals and


should not return to work until the
signs and symptoms and abnormal
biochemical

results

have

disappeared.

Environmental and Occupational Medicine


2nd Edition Little Brown & Co, Boston,
1992: 881.
2. Poisoning & Drug overdose Olson KR a
Lang

clinical manual 1999,497t Poisoning

& Drug overdose Olson KR a Lang clinical


manual 1999, 104-5

Recommend the worker for return to


work when the workplace hygiene is
safe and healthy and does not place
the worker at increased risk of
material impairment to health from
exposure to

b-

naphthylamine.
6.3 TREATMENT
All cases of poisoning must be immediately
removed from exposure and referred for
hospital treatment.
Wash contaminated areas of body with
soap and water
7.0

PREVENTIVE MEASURES
Education of worker not to smoke as
this chemical is found in cigarette
smoke,
Engineering

control,

Adequate

ventilation,
Approved PPE, Any self-contained
breathing apparatus with a full facepiece and operated in a pressure
demand or positive pressure mode.
Chemical goggles, mechanical filter
respirator.

1.0 SYNONYMS: 1 Naphtalamine


Physicochemical properties
1-Naphthylamine (often contains 2naphthylamine as an impurity)
White to reddish lustrous crystals.
It is an aromatic amine.

Signage CARCINOGEN.

Route of absorption

8.0 REFERENCE
1. Brsant-Rauf PW Goldstein MD Bladder
Carcinogens and Surveillance

24. 1- NAPHTHYLAMINE
& ITS SALTS

Inhalation. Skin

in

Department of Occupational Safety and Health (DOSH) Malaysia

85

Guidelines On Medical Surveillance

2.0

OCCUPATIONS AT RISK OF

4.2

EXPOSURE

EXAMINATIONS:

Chemical synthesis
Dyes

TOXIC EFFECTS

3.1

ACUTE EFFECTS

MEDICAL

Annually as for pre-employment.


4.3

Rubber
3.0

PERIODIC

WHERE
FOLLOWING

INDICATED,
TESTS

THE

MAY

BE

DONE
Full blood count.
Urine examination every 6 months.

Methemoglobinemia

5.0

Hematuria

INDICATIONS

FOR

MEDICAL

REMOVAL PROTECTION

Dysuria

All cases of definite or suspected

3.2 CHRONIC EFFECTS

poisoning and excessive absorption.

Haemorrhagic cystitis

Dermatitis
Bladder cancer, skin cancer
A2 Suspected Human Carcinogen
4.0 MEDICAL SURVEILLANCE
PROGRAMME
Any work where workers are exposed to
levels of airborne levels, which are liable to

All cases recommended for and


suspected cases of poisoning /
excessive absorption must be
notified to DG (DOSH).

6.0 FOLLOW-UP ACTION


Repeat tests
6.1 ABNORMAL RESULTS

be in excess of half the -in-air standard,

If the urine symptoms & signs persist, a

and or where there is significant risk of

repeat test must be done immediately.

ingesting it.

6.2 MEDICALLY REMOVED WORKER &

Screening of workers can done as for

RETURN TO WORK
All suspended cases should have

benzidine.

repeat
4.1 PRE-PLACEMENT MEDICAL

relevant

urine

examinations

biochemical

tests

(and
where

indicated) at 3-monthly intervals and

EXAMINATIONS:
Clinical examination & baseline data with

should not return to work until the

particular attention to :

signs and symptoms and abnormal

Kidneys

biochemical

Neurological &

disappeared.

estimation

have

Recommend the worker for return to

Respiratory system
Urine

results

(early morning

specimen corrected for creatinine)

work when the workplace hygiene is


safe and healthy and does not place
the worker at increased risk of

Department of Occupational Safety and Health (DOSH) Malaysia

86

Guidelines On Medical Surveillance

material impairment to health from


exposure to 1-naphthylamine.
6.3 TREATMENT
All

cases

of

poisoning

must

be

immediately removed from exposure


and referred for hospital treatment.
Irrigate eyes with water
Wash contaminated areas of body
with soap and water
Gastric larvage, if ingested, followed
by catharsis
7.0 PREVENTIVE MEASURES
Adequate

ventilation,

Chemical

goggles, Rubber gloves, appropriate


signage.
8.0 REFERENCES
Plunkett E R Handbook of industrial
Toxicology Heyden 1986.

25. ORTHOTOLIDINE AND ITS SALTS

1. SYNONYMS: bianisidine, 3,3


dimethylbenzidine
Physicochemical properties
White to reddish solid. Decomposes on
burning, producing hazardous

oxides of

nitrogen.
PEL 8 hr TWA: 0
Route of entry
Inhalation

Department of Occupational Safety and Health (DOSH) Malaysia

87

Guidelines On Medical Surveillance

Mode of action

4.3

WHERE

Bladder cancer

FOLLOWING

Skin irritant

DONE

2.0

OCCUPATIONS AT RISK OF
EXPOSURE

INDICATED,
TESTS

THE

MAY BE

Blood, Full blood count, Urine examination


every 6 months.
5.0 INDICATIONS FOR MEDICAL

Chemical synthesis

REMOVAL PROTECTION
3.0 TOXIC EFFECTS

All cases of definite or suspected poisoning

3.1 ACUTE EFFECTS

and excessive absorption.

Irritant to eyes, skin, respiratory tract,

All cases recommended for MRP and


suspected cases of poisoning excessive

liver, kidney, bladder

absorption must be notified to the DG

Cough

(DOSH).

3.2 CHRONIC EFFECTS


Skin irritation

6.0 FOLLOW-UP ACTION

Mammary gland tumours (IARC 2B)

6.1

A carcinogen in test animals

ABNORMAL RESULTS
If the urine symptoms & signs persist,

4.0 MEDICAL SURVEILLANCE

PROGRAMME

repeat

test

must

be

done

immediately.

Indications:
Any work where workers are exposed to

6.2 MEDICALLY REMOVED WORKER

levels of airborne levels which are liable to

All suspended cases should have

be in excess of half the-in-air standard and

repeat

or where there is significant risk of

relevant

ingesting it.

indicated) at 3-monthly intervals and

urine

examinations

biochemical

tests

(and
where

should not return to work until the


4.1 PRE-EMPLOYMENT MEDICAL

signs and symptoms and abnormal


biochemical

EXAMINATION
Clinical examination with particular

results

have

disappeared.
Recommend the worker for return to

attention to kidneys
neurological and

work when the workplace hygiene is

respiratory system.

safe and healthy and does not place

Urine

estimation

(early

morning

specimen corrected to SG of 1.016)


4.2 PERIODIC MEDICAL EXAMINATION

the worker at increased risk of


material impairment to health from
exposure to orthotolidine and its
salts.

To be conducted annually.
Department of Occupational Safety and Health (DOSH) Malaysia

88

Guidelines On Medical Surveillance

6.3

TREATMENT
All

cases

of

poisoning

must

be

immediately removed from exposure


and referred for hospital treatment.
Irrigate eyes with water
Wash contaminated areas of body
with soap and water
Gastric larvage, if ingested, followed
by catharsis
7.0

PREVENTIVE MEASURES
Adequate ventilation,
Chemical goggles, mechanical filter
respirator,
Rubber gloves
Appropriate signage

8.0

REFERENCES

1.

Olson KR. Poisoning & Drug

overdose,

Lang

Clinical

manual:

Prentice-Hall Int. (UK) Ltd., London; 1999:

26. DIANISIDINE AND ITS SALTS

522t.
2.

NIOSH USA

1.0 SYNONYMS: o, o Dianisidine


Physicochemical properties
White to violet crystals
Insoluble in alcohol and benzene
It is an aromatic amine
PEL 8 hr TWA: 0
Route of Entry
Inhalation
Dermal
CONFIRMED CARCINOGEN
2.0 OCCUPATIONS AT RISK OF
EXPOSURE
Chemical synthesis

Department of Occupational Safety and Health (DOSH) Malaysia

89

Guidelines On Medical Surveillance

6.0 FOLLOW-UP ACTION

Dye intermediate
Printing

6.1 ABNORMAL RESULTS

3.0 TOXIC EFFECTS

If results are abnormal, repeat it and if still


abnormal remove the worker and refer to

3.1 ACUTE EFFECTS


Irritant to eyes, skin, upper respiratory

the urologist.
6.2 MEDICALLY REMOVED WORKER &

tract

RETURN TO WORK

Induces methaemoglobinaemia

All suspended cases should have

Toxic hepatitis

repeat

3.2 CHRONIC EFFECTS

examinations

Carcinogen: cancer of the bladder


MEDICAL

investigation

SURVEILLANCE

and should not return to work until the


signs and symptoms and abnormal

General examination with emphasis to

biochemical

the renal and haematological system.

disappeared.

Urine cytology

have

work when the workplace hygiene is


safe and healthy and does not place

EXAMINATION

the worker at increased risk of

Clinical examination and baseline data with

material impairment to health from

particular attention to:

exposure to dianisidine and its salts.

Urine cytology

6.2 TREATMENT

Renal function test

All

4.2 PERIODIC MEDICAL EXAMINATION


pre-placement,

results

Recommend the worker for return to

4.1 PRE-PLACEMENT MEDICAL

for

relevant

biochemical tests where indicated

PROGRAMME

As

and

urine

poisoning

be

Wash contaminated areas of body


with soap and water.

5.0 INDICATIONS MEDICAL REMOVAL


7.0

PREVENTIVE MEASURES
Improvement

in

work-process

poisoning /disease and excessive

workplace hygiene

absorption.

Adequate ventilation,

All cases recommended for MRP and

must

and referred for hospital treatment.

annually.

All cases of definite or suspected

of

immediately removed from exposure

conducted

PROTECTION

cases

Approved

Personal

Protective

suspected cases of poisoning excessive

equipment, Chemical goggles

absorption must be notified to the DG

Appropriate signage

(DOSH).

Department of Occupational Safety and Health (DOSH) Malaysia

&

90

Guidelines On Medical Surveillance

8.0 REFERENCES
1.

International Labour Office:

Encyclopaedia of Occupational Health and


Safety, Geneva, 4th edition, 1998

27. DICHLOROBENZIDINE
& ITS SALTS
1.0 SYNONYMS : DCB, 3,3-dichlorobiPhenyl-4,4diamine
Physicochemical properties
Grey to purple crystalline solid with a faint
odour.
PEL 8 hr TWA : 0
Absorption
Inhalation
Well absorbed through the skin
Gastrointestinal tract
2.0 OCCUPATIONS AT RISK OF
EXPOURE
Chemical synthesis
3.0 TOXIC EFFECTS
3.1 ACUTE EFFECTS
Department of Occupational Safety and Health (DOSH) Malaysia

91

Guidelines On Medical Surveillance

General headache dizziness, nausea,

Biological monitoring is by testing Benzidine


in urine.

vomiting
Skin allergic reaction, dermatitis,

It is suggested that the medical surveillance

Caustic to skin

for

Eye severe irritation

conducted by using the principles and

respiratory

disease

should

be

methods recommended in the modified


3.2 CHRONIC EFFECTS

Medical

Causes blood in urine, and painful,

Research

Council

London

Questionnaire on respiratory symptoms.

difficult, or frequent urination

Please use the format developed by Prof

Sensitizer

Madya Noor Hashim Ismail et al Hospital,

Liver and breath cancer

UKM. Cheras.

Reduced fertility
IARC 2B Probable Human carcinogen

4.2 PERIODIC MEDICAL EXAMINATION


Conducted annually but much more
frequently if exposure is high.

ACGIH A3 Animal carcinogen

Urine cytology

Causes Bladder cancer

Urine benzedine
Full blood count

3.0 MEDICAL SURVEILLANCE


PROGRAMME
Any work where workers are exposed to
dichlorobenzidine &
Please

refer

Recommended

5.0

REMOVAL PROTECTION

its salts.
to

Benzidine

guidelines

for

screening.
4.1 PRE-PLACEMENT MEDICAL
EXAMINATION
Clinical examination and baseline data with
particular attention to:
General health profile Liver, Skin, Respiratory tract, Kidney &
full blood picture.
Specific Urine cytology

All cases of definite or suspected

for

bladder

INDICATIONS FOR MEDICAL

poisoning and excessive absorption.


All cases recommended for MRP and
suspected cases of poisoning / excessive
absorption must be notified to the DG
(DOSH).
6.0

FOLLOW-UP ACTION

6.1

ABNORMAL RESULTS

If the urine levels are exceeded, a repeat


test must be done immediately. Refer to
urologist.
6.2 MEDICALLY REMOVED WORKER &
RETURN TO WORK

Urine benzedine

Department of Occupational Safety and Health (DOSH) Malaysia

92

Guidelines On Medical Surveillance

All suspended cases should have

Control System, A Lange clinical

repeat tests

manual,

Return to work is when there are no

Ltd,London,1999:461t.

Prentice

Hall

Int.(UK)

symptoms and sign of disease.


Recommend the worker for return to
work when the

workplace hygiene

is safe and healthy and does not


place the worker at increased risk of
material impairment to health from
exposure to.

dichlorobenzidine & its

salts.
6.3 TREATMENT
First Aid: Shower as soon as possible
unless contraindicated by physical injuries.
7.0

PREVENTIVE MEASURES
Improvement in work process
Work-place hygiene
Use of approved PPE. A complete
respiratory

protection

Mechanical

programme.

filter

Pressurized

suit

respirator.
in

particular

hazardous places,

Chemical

goggles, Rubber gloves.


Compulsory

changing

of

working

clothes.

biphenyl
Physicochemical properties: White solid
with a sweet odour.
PEL 8hr TWA: 0

Dermal- extremely well absorbed


Eye contact
Safety

and

Health

Guideline for 3,3 dichlorobenzidine,

5.

1.0 SYNONYMS: 4-nitrobiphenyl, p- nitro

Inhalation

8.0 REFERENCES
Occupational

NITRODIPHENYL

Route of Absorption

Appropriate signage

4.

28.

Ingestion
Metabolised to 4-Aminodiphenyl which is a

Potential Human Carcinogen OSHA

potent carcinogen in humans.

USA.

Thermal

Mycroft FJ, Hiatt PH . The toxic

oxides of nitrogen.

hazards of industrial and Occupational


chemicals In : Olson KR, Poisoning &
Drug Overdose by California Poison

breakdown

products

include

2.0 OCCUPATIONS AT RISK OF


EXPOURE

Department of Occupational Safety and Health (DOSH) Malaysia

93

Guidelines On Medical Surveillance

Chemical

intermediates

in

the

synthesis of pharmaceutical products.

Bladder cystoscopy if indicated.


5.0 INDICATIONS MEDICAL REMOVAL

3.0 TOXIC EFFECTS

PROTECTION
All cases of definite or suspected poisoning

3.1 ACUTE EFFECTS

/disease and excessive absorption.

Headache

All cases recommended for MRP and

Lethargy

suspected cases of poisoning excessive

Painful urination

absorption must be notified to the DG

Blood or pus in the urine

(DOSH).

3.2 CHRONIC EFFECTS


Headache

weakness

dizziness

6.0

FOLLOW-UP ACTION

6.1

ABNORMAL RESULTS

feeling of euphoria breathing difficulty

If abnormal, symptoms & signs persist, a

(dyspnoea)

repeat test must be done immediately.

Impaired

muscular

coordination

(ataxia)
Blood or pus in the urine and painful or
frequent urination

Refer to urologist.
6.2 MEDICALLY REMOVED WORKER &
RETURN TO WORK

All suspended cases should have


repeat

4.0

examinations

MEDICAL SURVEILLANCE

signs and symptoms and abnormal

as for

biochemical

Benzidine
PRE-PLACEMENT MEDICAL

have

Recommend the worker for return to


work when the workplace hygiene is
safe and healthy and does not place

Clinical examination and baseline data with

the worker at increased risk of

particular attention to:

material impairment to health from

Kidneys - urine cytology

exposure to Nitrophenyl.

Neurological and
Respiratory system
PERIODIC

results

disappeared.

EXAMINATION

4.3

relevant

and should not return to work until the

Please refer to Recommended guidelines

4.1

and

urine

biochemical tests where indicated

PROGRAMME
for bladder cancer screening

investigation

6.3
MEDICAL

EXAMINATION
As for Pre-employment. To be done

TREATMENT
All

cases

of

poisoning

must

be

immediately removed from exposure


and referred for hospital treatment.

annually but if exposure is high carry it out.


Department of Occupational Safety and Health (DOSH) Malaysia

94

Guidelines On Medical Surveillance

Wash contaminated areas of body


with soap and water.
7.0 PREVENTIVE MEASURES
Improvement in work-process & workplace hygiene
Adequate ventilation
Personal Protective Equipment
Chemical goggles
Appropriate signage
8.0 REFERENCES
9.

International

Labour

Encyclopaedia

of

Office:

Occupational

Health and Safety, Geneva, 4th


29.0 NITRO OR AMINO

edition, 1998.
10. Olson

KR

Poisoning

and

Drug

Overdose A Lang clinical manual


1999: 499t.
11. Occupational

Safety

and

DERIVATIVES

PF PHENOL

AND OF BENZENE OR

ITS

HOMOLOGUES

Health
29.1 NITROBENZENE

Guideline for 4-Nitrobiphenyl U.S.


NIOSH, 1998.

1.0 PHYSICOCHEMICAL PROPERTIES:


Colourless oily liquid turns yellow on
exposure to air. Odour of bitter almonds
PEL 8hr TWA: 1 ppm
Route of entry
Inhalation-80% is absorbed through lungs.
Skin absorption of the vapour is possible,
Liquid nitrobenzene is readily absorbed by
the skin.
Biotranformation
It is metabolised by both oxidation and
reduction: the former leads to p-nitrophenol

Department of Occupational Safety and Health (DOSH) Malaysia

95

Guidelines On Medical Surveillance

and the latter to aniline, which is further

lasting effects on the blood, liver, and

oxidised to p-amniophenol

nervous system.

Excretion
16% of absorbed dose is excreted in urine
as p-nitrophenol and less than 10% as pamniophenol.

Level of when
methaemoglo
bin level is
g/100 g Hb

Symptoms/ signs

15

Cyanosis,
blue
lips,
nose,
earlobes.
Individual feels well and
has no complaints

Both are eliminated as sulphate and


glucuronide conjugates.
2.0

OCCUPATIONS AT RISK OF
EXPOSURE
Chemical

40- 70
workers

in

chemical

intermediate and solvent

Headache,
weakness,
dizzy, ataxia, dyspnea on
mid
exertion,
tachycardia, nausea, vomiting,
drowsiness

Dye makers
Explosive manufacture
3.0 TOXIC EFFECTS

> 70

Coma

85-90

Lethal

Blood effects as aniline

Source: World Health Organisation Early


detection of occupational diseases, 1986
EXPOSURE EFFECTS

Skin-dermatitis (due to primary irritation or

RELATIONSHIP

3.1 ACUTE EFFECTS

sensitisation)
Symptoms; Irritating to eyes. Signs and

Nitrobenzene
mg/m3 air

signs of overexposure result from loss of


oxygen carrying of the blood. Onset of

15-30

symptoms of methaemoglobinemia may be


insidious and may be delayed up to 4

Symptoms/ signs
Headache,
vertigo,
Effects of increased
methaemoglobin
&
sulfahaemoglobin

hours.
Headache is commonly the first sign and

200 for 6 months

Intoxication, anaemia

becomes severe as methaemoglobinemia


increases.

3.2

CHRONIC EFFECTS

Signs: ataxia, cyanosis develops when

Blood-anaemia

methaemoglobin level is 15-g/100 g Hb or

Liver- jaundice,

more. Effects of methaemoglobinaemia are

Systemic Weight loss, poor appetite

regarded as acute and promptly reversible.

Bladder tumours

Severe exposures may produce more

Department of Occupational Safety and Health (DOSH) Malaysia

96

Guidelines On Medical Surveillance

4.0

4.1

MEDICAL SURVEILLANCE

PRE-PLACEMENT MEDICAL
EXAMINATION

PROGRAMME
Any work where workers are exposed to

Clinical examination & baseline data with

levels of airborne levels which are liable to

particular attention to detecting pre-existing

be in excess of half the -in-air standard and

abnormalities of: -

or where there is significant risk of

Cardiovascular system,

ingesting it.

Lungs and

BIOLOGICAL ASSESSMENT
Measurement of

urinary p-nitrophenol at

end of work-shift.

Blood
Susceptible

are

haemoglobinopathies,

hereditary
congenital

disease, causing cyanosis and, chronic

Level of
nitrobenzene in air
Mg/m3

p-nitrophenol
mg/Litre of urine

1.5-5.5

Source: World Health Organisation Early


detection of occupational diseases. 1986

alcoholism,
Urine

estimation

(early morning

specimen corrected to SG of 1.016)


4.2 PERIODIC MEDICAL EXAMINATION
An annual check similar in content to the
pre-placement examination is appropriate.
Blood test to detect:

Measurement of blood methaemoglobin

Anaemia (Hb, haematocrit)

(normal level of 1.5 g per 100g Hb) may

Abnormalities of liver function

also prove to

heart

be useful method of

4.3

assessing exposure.

WHERE
FOLLOWING

INDICATED,

THE

TESTS

MAY

bodies

in

BE

DONE
BIOLOGICAL EXPOSURE

Blood

DETERMINANTS
Determinants

Heinz

severe

poisoning

Sampling
time

BEI

Total pnitrophenol in
urine

End of
shift at
end of
work week

5 m g/g
creatinine

Methemoglobin

End of

in blood

shift

Full blood count


Urine every 6 months
5.0

INDICATIONS FOR MEDICAL


REMOVAL PROTECTION.

1.5 %
Haemoglobin

Source: TLVs & BEIs ACGIH 2000

All cases of definite or suspected


poisoning and excessive absorption.
All

cases

recommended

for

suspension and suspected cases of


poisoning / excessive absorption
must be notified to the DG (DOSH).

Department of Occupational Safety and Health (DOSH) Malaysia

97

Guidelines On Medical Surveillance

6.0

8.0

FOLLOW-UP ACTION

Repeat tests
6.1

1.

ABNORMAL RESULTS

World Health Organisation; Early

detection

If the symptoms & signs persist, a repeat


test must be done immediately.
6.2

REFERENCES

of

occupational

diseases

Geneva, 1986: 138-141.


2.

American

Conference

of

MEDICALLY REMOVED WORKER

Governmental

& RETURN TO WORK

Documentation of the Threshold Limit

All suspended cases should have


repeat

urine

examinations

(and

relevant biochemical tests where


indicated) at 3-monthly intervals and
should not return to work until the
signs and symptoms and abnormal
biochemical

results

have

disappeared.

Industrial

Hygienist:

Values and Biological Exposures Indices,


Cincinnati 1999.
3.
to

Control of Substances Hazardous


Health

(COSHH)

Regulation11-Health
nitrobenzene:

Regulations:
Surveillance-

pneumo-coniosis

in

The

Health and Safety Fact book Health &


safety Executive, Professional Publishing

Recommend the worker for return to


work when the

Ltd London, 1989:1/5.

workplace hygiene

is safe and healthy and does not


place the worker at increased risk of
material impairment to health from
exposure to nitrobenzene.
6.3

TREATMENT
Almost same as for aniline poisoning.
All

cases

of

poisoning

immediately

must

removed

be
from

exposure.
Hospital treatment.
Irrigate eyes with water
Wash contaminated areas of body with
soap and water
7.0

PREVENTIVE MEASURES
Adequate ventilation
Chemical goggles, mechanical filter
respirator, rubber gloves
Appropriate signage

Department of Occupational Safety and Health (DOSH) Malaysia

98

Guidelines On Medical Surveillance

29.2

ANILINE

1.0 PHYSICOCHEMICAL PROPERTIES


Colourless to pale yellow oily liquid with an
aromatic odour.
PEL 8hr TWA : 2 ppm
Route of absorption
Inhalation-mainly
Dermal especially of liquid, (vapour)
through contaminated clothes, gloves &
shoes.
Biotransformation: 15-60 % of absorbed
aniline is oxidised to p-aminophenol. Which
is excreted in urine as glucuronide and
sulphate

conjugates.

metabolite,

phenyl

The

intermediate

hydroxylamine

is

responsible for toxic effects of aniline


mainly methaemoglobinemia.

Excretion It is not found in expired air. In


exposed

workers

the

urinary

p-

aminophenol

Department of Occupational Safety and Health (DOSH) Malaysia

99

Guidelines On Medical Surveillance

Appears to be directly related to the blood


methaemoglobin

concentration.

level

p-

15 mg/100g Hb

aminophenol accounts for 20-40 % of the

Cyanosis, feel
unwell

absorbed dose.
40 mg/100g Hb

Non -occupational exposure.


Aniline is present in household dyes. It is a
metabolite

of

Nitrobenzene,

phenylhydroxylamine.
acetanilide,

Weak, dizzy,
Ataxia, dyspnoea,

40- 70 mg/100 Hb

on mild exertion,
tachycardia,

phenacetin,

Headache

phenazopyridine and some pesticides.


>70 mg/100 Hb

Coma

85-90 mg/100 Hb

Lethal

Elevated level of methaemoglobin of > 1.5


g per 100 g haemoglobin.

Source: World Health Organisation Early


detection of occupational diseases, 1986
2.0

OCCUPATIONS AT RISK OF

Exposure lasting several hrs at 25-200 mg

EXPOSURE

causes mild symptoms and at above 400-

Chemical

Manufacture

rubber,

of

dyes,

accelerators

antioxidants,

and

pharmaceuticals,

resins, varnishes, perfumes and


Rubber works used as a solvent in
vulcanizing

agent

in

rubber

mg/m3

for

hour

serious

3.2

4.0

CHRONIC EFFECTS
Liver & cerebral effects
MEDICAL SURVEILLANCE
PROGRAMME

manufacture

Any work where workers are exposed to

3.0

TOXIC EFFECTS

3.1

ACUTE EFFECTS

levels of airborne levels which are liable to


be in excess of half the -in-air standard and

Liquid aniline is irritating to the eyes

600

Methaemoglobin results.

Following skin absorption symptoms

or where there is significant risk of


ingesting it.

may be delayed for 4 hrs, it induces

Biological assessment - urinary p-amino-

formation

of

phenol

(reducing

oxygen

methaemoglobin
transport).

Symptoms become intense as the


level of methaemoglobin increases.
Methaemoglobin

Symptoms / signs

Exposure
hours of
aniline for 8
hrs at air
concentrati
on of
mg/m3

Department of Occupational Safety and Health (DOSH) Malaysia

Rates of
urinary paminophenol

Urinary paminophenol
mg within
first 24
hrs.

100

Guidelines On Medical Surveillance

Urine

mg/m3
5

At 4 the hour
1.5 mg/hr

35

19

At 6 th hour
13 mg/hr

150

estimation

specimen

(early morning

corrected

for

creatinine)
4.2

Source: World Health Organisation Early


detection of occupational diseases, 1986

PERIODIC

MEDICAL

EXAMINATIONS
Annual review similar to the pre-placement
examination is appropriate.
4.3

WHERE INDICATED, THE


FOLLOWING TESTS MAY BE
DONE

BIOLOGICAL EXPOSURE

Blood-Erythroblastic

DETERMINANTS

inclusions

(Heinz bodies develop in serious


poisoning but haemolysis is rare

Determinants

BEI

Samplin

Full blood count

g time

Urine examination every 6 months

Total

End of

50mg/g

p-aminophenol

shift

creatinine

5.0

INDICATIONS

FOR

MEDICAL

REMOVAL PROTECTION

in urine
Methemoglobin
in blood

During or
End of
shift

1.5% of
hemoglobin

All cases of definite or suspected


poisoning and excessive absorption.
All cases recommended for MRP and

Source : TLVs & BEIs ACGIH 2000

suspected cases of poisoning excessive

4.1

PRE-PLACEMENT MEDICAL

absorption must be notified to the DG

EXAMINATIONS

(DOSH).

Clinical examination & baseline data with


particular attention to:
Cardiovascular system
Respiratory

6.1

Blood
Special

ABNORMAL RESULTS
If the urine symptoms

attention

individuals

6.0 FOLLOW-UP ACTION


Repeat tests

should

hyper

Methaemoglobinemia.

be

paid

sensitive

to
to

& signs

persist, a repeat test must be done


immediately.
Refer

urologist

for

abnormal

cytology.
6.2 MEDICALLY REMOVED WORKER &
RETURN TO WORK

Department of Occupational Safety and Health (DOSH) Malaysia

101

Guidelines On Medical Surveillance

All suspended cases should have


repeat

urine

examinations

Adequate ventilation to control vapour


All workers should know how to

(and

recognise early signs of cyanosis

relevant biochemical tests where


indicated) at 3-monthly intervals and

Skin contact must be avoided by use

should not return to work until the

of

signs and symptoms and abnormal

Chemical goggles, mechanical filter

biochemical

respirator, Rubber gloves

results

have

disappeared.

impervious

boot

&

gloves

Appropriate signage

Recommend the worker for return to


work when the

workplace hygiene

is safe and healthy and does not

1.

REFERENCES
World Health Organisation Early

place the worker at increased risk of

detection of occupational diseases

material impairment to health from

Geneva, 1986: 134-138.

exposure to aniline
6.3

8.0

2.

TREATMENT

Control of Substances Hazardous to


Health

All aniline on the body must be

(COSHH)

Regulations:

Regulation11-Health

Surveillance-

removed immediately remove and

Aniline: in The Health and Safety

discard all clothing, gloves and

Fact

footwear.

book

Health

&

safety

Executive, Professional Publishing

Wash the whole body with soap and

Ltd London, 1989:1/5.

water.
Pay special attention to hair, finger and

29.3 TOLUENE

toe nails, nostrils, ear canal.


Determine

Methaemoglobin

level

every 3-6 hours for 18-24 hrs.

1.0 SYNONYMS: Methylbenzene,

Ascorbic acid (IV) and methylene

Phenylmethane, toluol

blue have been used in severe


cases
All

cases

of

poisoning

must

be

immediately removed from exposure


and referred for hospital treatment.
Irrigate eyes with water
Wash contaminated areas of body with
soap and water
Gastric lavrage, if ingested, followed
by catharsis
7.0

volatile,

Physicochemical properties:
colourless

with

characteristic

odour.

Vapour is explosive. It is flammable.


PEL 8hr TWA: 50 ppm
Absorption
Inhalation of its vapours- mainly.
About

40-60%

of

inhaled

amount

is

retained in body
Skin

PREVENTIVE MEASURES
Department of Occupational Safety and Health (DOSH) Malaysia

102

Guidelines On Medical Surveillance

Biotransformation About 60-80 % is

food with benzoic acid or benzoates rarely

metabolised into benzoic acid, which then

exceeds 0.95 mol per mol of creatinine

conjugates with glycine to form hippuric

(1.5g/g).

acid.
About 29% of toluene is

Excretion
exhaled.

Hippuric

acid

is

rapidly

eliminated in urine ( almost entirely in 24

Exposure level to
toluene mg/m3 for 8
hours

Urinary hip uric


acid per mol
creatinine

200

0.95mol (1.5 g/g)

375

1.58 mol or

hours) .
2.0

OCCUPATIONS

AT

RISK

OF

EXPOSURE

2.5.g/g

Petrochemical workers in toluene


production
Chemical industry & laboratories

Source: World Health Organisation Early


detection of occupational diseases, 1986

using toluene as solvent for rubber,

BIOLOGICAL EXPOSURE

tar, asphalt, and cellulose paints

DETERMINANTS

and varnishes.
3.0

TOXIC EFFECTS

3.1

ACUTE EFFECTS

Narcotic- headache, dizzy, drowsy,


unconscious

death

due

to

of

co-

respiratory arrest
Neurotoxic

impairment

Determinants

Sampling
time

BEI

O - Cresol in urine

End of shift

0.5
mg/L

Urinary hippuric
acid in urine

End of shift

1.6
g/g
creati
nine

Toluene in venous
blood

Prior to last
shift of
workweek

0.05
mg/L

ordination and memory, nausea,


anorexia.
4.0

MEDICAL SURVEILLANCE
PROGRAMME

Any work where workers are exposed to


levels of airborne levels which are liable to
be in excess of half in the -in-air standard
and or where there is significant risk of
ingesting it.

Source: TLVs & BEIs ACGIH 2000


4.1

PRE-PLACEMENT MEDICAL
EXAMINATIONS

Clinical examination and baseline with


particular emphasis on:
Nervous system

Biological assessment

Liver

Measurement of urinary hippuric acid at

Kidney

end of work-shift is most important method.

Worker with increased susceptibility to

The concentration of hippuric acid from

toluene:

Department of Occupational Safety and Health (DOSH) Malaysia

103

Guidelines On Medical Surveillance

should not return to work until the

Chronic diseases of central nervous

signs and symptoms and abnormal

system,

biochemical

Hepatic or
Renal

function

Recommend the worker for return to

PERIODIC

work when the

MEDICAL

place the worker at increased risk of

Same as pre-placement carried out every

material impairment to health from

year or 2-3 years depending on the level of

exposure to toluene.

exposure, symptoms and signs of disease


6.3

and biological monitoring results.

TREATMENT
All cases of poisoning must be

WHERE INDICATED, THE

immediately removed from exposure

FOLLOWING TESTS MAY BE

and referred for hospital treatment.

DONE:

rrigate eyes with water

Full blood count

Wash contaminated areas of body

Urine every 6 months


5.0

workplace hygiene

is safe and healthy and does not

EXAMINATIONS

4.3

have

disappeared.

impairments

susceptibility.
4.2

results

with soap and water

INDICATIONS FOR MEDICAL

7.0

REMOVAL PROTECTION

PREVENTIVE MEASURES
Adequate ventilation

All cases of definite or suspected

Chemical goggles

poisoning and excessive absorption.

Chemical filter respirator

All cases recommended for MRP and

Rubber gloves

suspected cases of poisoning excessive

Appropriate Signage

absorption must be notified to the DG


(DOSH).

8.0

6.0 FOLLOW-UP ACTION

1.

Repeat tests

detection

6.1 ABNORMAL RESULTS

Geneva, 1986: 127-30.

If the urine symptoms & signs persist, a

REFERENCES
World

Health
of

Organisation;

occupational

3. American

Early

diseases

Conference

of

repeat test must be done immediately.

Governmental Industrial Hygienist:

6.2 MEDICALLY REMOVED WORKER &

Documentation of the Threshold

RETURN TO WORK

Limit

All suspended cases should have


repeat

urine

examinations

(and

Values

Exposures

and

Biological

Indices,

Cincinnati

1999.

relevant biochemical tests where


indicated) at 3-monthly intervals and
Department of Occupational Safety and Health (DOSH) Malaysia

104

Guidelines On Medical Surveillance

Petrochemical
29. 4

XYLENE

workers

in

xylene

production

1.0 SYNONYMS: Dimethylbenzene, Xylol

Workers in chemical industry 9

Physicochemical properties

substrate for organic synthesis) &

Colourless,

volatile

liquid

with

typical

laboratories using xylene as raw

aromatic odour. It is flammable

material or solvent for rubber, tar,


asphalt,

PEL 8 hr TWA : 100 ppm

cellulose

paints

and

varnishes.

Route of absorption

Paint (thinner for paints & lacquers)

Mainly through inhalation of its vapours.

and printing

About 40-60% of total inhaled amount is

(Rotogravure) workers

retained in the body.


Skin absorption through direct contact with
liquid
Biotransformation
About

95

of

3.0

TOXIC EFFECTS

3.1

ACUTE EFFECTS

Narcotic
absorbed

xylene

is

unconsciousness.

metabolised to almost entirely to methyl


benzoic acid, which then conjugates with
glycine to form methylhippuric acid.

3.2

after

due

to

irritability,
disorders,

fatigue,
sleepiness

at night.

acid) in urine is rapid and reaches


hours

Death

during the day and sleep disorders

air and of its metabolites (methylhippuric


18

drowsy,

CHRONIC EFFECTS
dyspeptic,

Elimination of unchanged xylene in exhaled

within

dizzy,

respiratory arrest is possible.

Headache,

Excretion

completion

effects-

4.0

MEDICAL SURVEILLANCE
PROGRAMME

termination of exposure.
Biological assessment

Any work where workers are exposed to

Measurement of urinary methylhippuric

levels of airborne levels which are liable to

acid is the most important method. A 8

be in excess of half the -in-air standard and

hour exposure to 200 mg of xylene/m3 of

or where there is significant risk of

air corresponds to a. urinary methylhippuric

ingesting it.

acid of about 0.00725 mol/lire (1.4 g/litre)

Exposure effect relationship

on the basis of samples collected from

Impairment of reaction time was observed

groups of workers at end of a work shift,

in volunteers exposed to 870 mg/m3 for 3

corrected for creatinine)

hours

2.0

OCCUPATIONS AT RISK OF

BIOLOGICAL EXPOSURE

EXPOSURE
Department of Occupational Safety and Health (DOSH) Malaysia

DETERMINANTS

105

Guidelines On Medical Surveillance

Determinants

Sampling
time

BEI

Urinary methyl
hippuric acid in
urine

End of

1.5 g/g
creatinine

shift

All cases of definite or suspected


poisoning and excessive absorption.
All cases with evidence of all cases
recommended

for

suspension

and

suspected cases of poisoning excessive


absorption must be notified to the DG

Source : TLVs & BEIs ACGIH 2000


4.1

(DOSH).

PRE-PLACEMENT MEDICAL
6.0 FOLLOW-UP ACTION

EXAMINATIONS
Clinical examination & baseline data with

Repeat tests

particular attention to:

6.1

kidneys

If the symptoms & signs persist, a repeat

Neurological and

test must be done immediately.

Respiratory system

6.2

SUSCEPTIBILITY
suffering

MEDICALLY REMOVED WORKER


& RETURN TO WORK

Pregnant women
Those

ABNORMAL RESULTS

from

chronic

diseases of:

All suspended cases should have


repeat

urine

examinations

(and

- Central nervous system or

relevant biochemical tests where

- Diseases impairing hepatic

indicated) at 3-monthly intervals and

Renal functions
4.2

PERIODIC

should not return to work until the


MEDICAL

signs and symptoms and abnormal

EXAMINATIONS

biochemical

Same as pre-placement, carried out every

disappeared.

year or 2-3 years depending on the level of

results

have

Recommend the worker for return to

exposure, symptoms and signs of disease

work when the

and biological monitoring.

is safe and healthy and does not

4.3

WHERE INDICATED, THE

place the worker at increased risk of

FOLLOWING TESTS MAY BE

material impairment to health from

DONE

exposure to xylene.

Specialised Neurological;
Psychiatric and
Psychological examinations may be
necessary
5.0 INDICATIONS FOR MEDICAL

workplace hygiene

6.3 TREATMENT
All

cases

of

poisoning

must

be

immediately removed from exposure


and
Referred for hospital treatment.

REMOVAL PROTECTION
Department of Occupational Safety and Health (DOSH) Malaysia

106

Guidelines On Medical Surveillance

Wash contaminated areas of body with


soap and water

NO2

Gastric larvage, if ingested, followed


by catharsis
7.0

Nitrogen tetraoxide (N2O4): ploymer of

Physicochemical properties
White solid with a sweet odour

PREVENTIVE MEASURES

PEL 8 hr TWA

Adequate ventilation,

Nitrous oxide

Chemical goggles/filter respirator,

Nitrogen dioxide

Rubber gloves

50 ppm
3 ppm

Nitrogen oxides (nitric oxide or nitrogen

Appropriate Signage

dioxide: not nitrous oxide are dangerous


chemicals commonly released from:
Nitrous or nitric acid

8.0 REFERENCES
1.

World

Health

Organisation:

Early

detection of occupational diseases.


Chapter 19, Diseases caused by
benzene its toxic homologues, 1986:
122-33.

Reactions between nitric acid and


organic materials
Burning of nitrocellulose and many
other products
Route of Absorption
Inhalation

2.

American

Conference

Governmental

Industrial

of

NITROGEN

DIOXIDE

is

irritant,

Hygienist:

hydrolyses to form nitric acid, nitrous acid

Documentation of the Threshold Limit

and nitric oxide in alveoli of lung this results

Values

in:

and

Biological

Exposures

Indices, Cincinnati 1999.


30. 1

NITROUS FUMES

1.0 SYNONYMS: Nitrogen oxides (NOx)

Delayed

on

set

of

chemical

pneumonitis. (Pulmonary oedema)


Nitrogen

oxides

can

oxidise

hemoglobin to methemoglobinem

(synonym: nitric oxides)


Nitrogen mono-oxide (NO) (synonym: nitric
acid)
Colourless, oxidises readily to NO2.The
sharp sweet odour occurs below the TLV
and is a good warning property.
Nitrogen dioxide (NO2) reddish brown
Dinitrogen monoxide (N2O)
(Synonym: nitrous oxide, laughing gas)

2.0 OCCUPATIONS AT RISK OF


EXPOSURE
Nitrogen dioxide-found industrially in
arc and inert gas shielded welding in
small-unventilated rooms. (Electric
arc welding)
By product in the manufacture of dyes
and explosives

Department of Occupational Safety and Health (DOSH) Malaysia

107

Guidelines On Medical Surveillance

Electroplating & engraving

In

May be evolved from silage

occurs usually after a latent period (6-24

Is found in engine exhaust

hrs, up to 72 hrs).

severe

cases,

pulmonary

oedema

Produced when stored grain with a


4.0 MEDICAL SURVEILLANCE

high nitrite content ferments


Dinitrogen

monoxide

is

used

an

Any work where workers are exposed to

anaesthetic gas.
3.0

PROGRAMME
levels of airborne levels which are liable to

TOXIC EFFECTS

These depend upon the type and amount


of gas. In this case it is for NITROGEN
DIOXIDE

be in excess of half the -in-air standard and


or where there is significant risk of
ingesting it.
4.1 PRE- PLACEMENT MEDICAL

3.1 ACUTE EFFECTS


Local

Conjunctivitis, corneal
ulceration

Respiratoy

Chest pain, pulmonary


odema

Central
nervous
system

Headache, dizzy, ataxia,


delirium, convulsions

GastroIntestinal

Nausea, vomiting, Abdominal


pain

EXAMIANTIONS
Clinical examination and baseline data with
particular attention to:
Respiratory and
Cardiovascular system.
4.2 PERIODIC

MEDICAL

EXAMIANTIONS

Decreased pulse rate,


Cardiac arrthymia, collapse

Circulatory

As for Pre-employment. To be done


annually but if exposure is high carry it out
more frequently.
4.3 WHERE INDICATED OTHER TESTS

3.2 CHRONIC EFFECTS (Inhalation)


May be delayed for 30 hours

MAY BE DONE
Methemoglobin determination may be

Headache, insomnia chronic bronchitis,

helpful.

emphysema.

CO2 in blood may be increased

Nitrous oxide has effects on reproduction,

Chest

blood, and nervous system. It causes


asphyxiation.
Nitric

oxides

X-rays-show

chemical

pneumonits or pulmonary oedema


5.0 INDICATIONS MEDICAL REMOVAL

may

cause

methemoglobinemia
Nitric oxide and nitric tetroxide are irritant
to the mucous membranes of the eyes an

PROTECTION
All cases of definite or suspected
poisoning /disease and excessive
absorption.

upper respiratory tract.


Department of Occupational Safety and Health (DOSH) Malaysia

108

Guidelines On Medical Surveillance

All cases recommended for suspension

Improvement in work-process &

and

workplace hygiene

suspected

cases of poisoning /

excessive absorption must be notified to


the Director

Adequate

General, Department of

Chemical goggles, Gas mask or

6.0 FOLLOW-UP ACTION

airline respirator

6.1 ABNORMAL RESULTS

Rubber

If abnormal, symptoms & signs persist, a

Appropriate Signage

All suspended cases should have

indicated and should not return to

8.0

REFERENCES

1.

International

Labour

Office:

work until the signs and symptoms

Encyclopaedia of Occupational Health

and abnormal biochemical results

and Safety, Geneva, 4th edition, 1998.

have disappeared.
Because

of

delayed

2. Information Notices on Diagnosis of


effects

all

Occupational

Diseases,

Head

workers with significant inhalation

Occupational Health and Hygiene Unit,

should be observed for several hours.

Public Health and safety at work

Recommend the worker for return to

Directorate,

work when the workplace hygiene is


safe and healthy and does not place
the worker at increased risk of

3.

All

cases

of

must

be

immediately removed from exposure


and referred for hospital treatment.

Handbook

of

Industrial

Toxicology

Barberton, Ohio, Hyden 1987.


4.

poisoning

Commission

Plunkett, Industrial Health Services,

exposure to nitrous fumes.


6.3 TREATMENT

European

Luxemburg 1994.

material impairment to health from

7.0

protective

days after filling.

RETURN TO WORK

and relevant biochemical tests where

and

No silo should be entered for 7

6.2 MEDICALLY REMOVED WORKER &

examinations

gloves

clothing

repeat test must be done immediately.

investigation,

Personal

Protective equipment,

Occupational Safety and Health.

repeat

ventilation,

Tse, RL et al Nitrogen Dioxide Toxicity:


Report of Four Cases in Firemen,
Journ. Am. Med. Assn., 1970:212-1431.

5. Olson KR Poisoning & Drug Overdose

Wash contaminated areas of body

by the faculty, staff and associates of

with soap and water.

the California Poison Control system, A

PREVENTIVE MEASURES

Lang Clinical Manual, 1999.

Department of Occupational Safety and Health (DOSH) Malaysia

109

Guidelines On Medical Surveillance

Onset is prompt but may be delayed up to


31.

PESTICIDES

12 hours.

(ORGANOPHOSPHATES ONLY)

OP

and

their

potent

sulfoxidation

1.0 Physicochemical properties

("-oxon")

There are hundreds of preparations of

acetylcholin-esterse,

organophosphate (OP) compounds. The

accumulation of excessive acetylcholine.

properties

Permanent

compositions

vary
of

according
active

to

and

the

inactive

ingredients.
PEL 8hr TWA depends upon the type of
organophosphate

derivatives

inhibit

the

allowing

damage

the

to

the

acetylcholinesterse, enzyme (aging) may


occur after a variable delay unless antidotal
treatment with an enzyme reactivator is
given.
Some OP (e.g. disulfoton, fenthion, others)

Route of absorption: Skin and eye are

are highly lipophilic and are stored in fat

the most common route of absorption in

tissue, which may lead to delayed and

agriculture.

persistent toxicity for several days after

Special Note: Organophosphates (OP) can

exposure.

be readily absorbed through the skin.

Generally effects are not apparent until

Lungs.

the activity of this enzyme is 30% of the

Gastrointestinal.

normal.

2.0 OCCUPATIONS AT RISK OF

Central Nervous System:

EXPOSURE

Anxiety,

Horticulture- gardeners, greenhouse

sleeplessness,

workers

convulsions.

Agriculture -garden pest control


operators, farmers
Vector control operators
Formulation (and manufacture of
organophosphates e.g. Insecticide

dizziness,
confusion,

headache,
coma,

Respiratory:
Dyspnoea, chest tightness, bronchospasm,
bronchial

hypersecretion,

pulmonary

oedema.

sprays

Gastrointestinal:

Laboratory workers analysing

Salivation, nausea, vomiting, abdominal

Organophosphates

colic, diarrhoea, pancreatitis.

Packing and redistribution of


Organophosphates.
3.0

TOXIC EFFECTS

3.1

ACUTE EFFECT

Ocular: Lacryimation, miosis, blurring


of vision
Muscular: fasciculation, cramps
3.2 CHRONIC POISONING

Department of Occupational Safety and Health (DOSH) Malaysia

110

Guidelines On Medical Surveillance

Non-specific:

4.1

Headache, quick onset of fatigue

Clinical examination and baseline data with

Disturbed sleep, anorexia


Central and Autonomic Nervous System
Nystagmus, tremors

particular emphasis on the:


Central

and

autonomic

nervous

system.

Failing memory, disorientation

Plasma cholinesterase estimation is

Peripheral Nervous System:

good

Paresis

enough

for

medical

surveillance.

Neuritis

However for treatment purposes, Red

Paralysis
Note: OP is commonly used in the field.
For the list of OP used in Malaysia please
refer to Booklet-List of Pesticides

blood cell acetyl cholinesterase (rbc ACHE)


estimation (venous blood in heparinised
container and should be sent immediately
to the laboratory in an ice box).

registered with the Pesticide Board,

4.2 PERIODIC MEDICAL

Department of Agriculture.

EXAMINATIONS

Examples are the Basudin 60 Dichlorvos


Dimethoate Dipterex Diazinon DDVP (2,2,
Dichlorovinyl 0, O-Dimethyl Phosphate)
Fenthion,

PRE-PLACEMENT MEDICAL
EXAMINATIONS

Malathion,

Parathion,

and

(6 MONTHLY)
Clinical

examination

including

plasma

ACHE estimation.
4.3 WHEN INDICATED THE

Tamaron.

FOLLOWING TEST MAY BE

4.0 MEDICAL SURVEILLANCE

CONDUCTED

PROGRAMME

Plasma cholinesterase estimation should

Any occupational exposure to OP.

be

carried

out

(especially

following

BIOLOGICAL EXPOSURE

accidental skin contact or acute high

DETERMINANTS

exposures or in suspected acute poisoning


cases).

Determinants

Cholinesterase
activity in red
cells
(confirmatory)

Sampling
Time
Discretionay

Cholinesterase
activity in
plasma
(Screening)

BEI

5.0 INDICATIONS FOR MEDICAL


REMOVAL PROTECTION

70% of
individual's
baseline
70% of
individual
's
baseline

All cases of definite or suspected


poisoning and excessive absorption.
Cases with plasma ACHE of less than
50%

of

the

pre-employment

or

laboratory's normal level.

Source: TLVs & BEIs ACGIH 2000


Department of Occupational Safety and Health (DOSH) Malaysia

111

Guidelines On Medical Surveillance

Cases with rbc ACHE of less than 50%

Recommend the worker for return to

of the pre-employment or laboratory's

work when the workplace hygiene is

normal level.

safe and healthy and does not place

Cases with rbc ACHE of between 50

the worker at increased risk of

and 70% of the pre-employment level

material impairment to health from

showing a fall of more than 10% in

exposure to organophosphates.

their repeat test results.


All cases of MRP and suspected cases of
OP poisoning/excessive absorption must
be notified to the DG (DOSH).

6.3

Treatment with atropine and/or 2-PAM (2pyridine-aldoxine

(a) Suspension includes suspension from


work with carbamates.

7.0

be

PREVENTIVE MEASURES
Pesticide application course for all the

available, use the lower limit of the

pesticide applicators,

laboratory as normal range as a baseline


previous

may

signs and symptoms.

(b) Where the pre-employment level is not

or

methiodide)

considered especially if there are clinical

Note:

forcomparison

TREATMENT

Approved

results:

Personal

Protective

equipment

whichever is higher.

Appropriate signage

6.0 FOLLOW-UP ACTION


Repeat tests.
6.1 ABNORMAL RESULTS
If the plasma ACHE level is between 50

8.0 REFERENCES
1

National

Institute

for

Occupational

and 70% of the pre- employment level, a

Safety and Health: Criteria for a

repeat test should be done one month

recommended standard (Occupational

later. A fall in the plasma ACHE level of

exposure

more than 10% in the repeat test should be

Department of Health, Education and

investigated to exclude poisoning.

Welfare, 1976: 92-107, 141-145.

6.2

MEDICALLY REMOVED WORKERS


& RETURN TO WORK

Supervision

of

US

Pesticide

State of California, Department of

repeat plasma ACHE estimations at

Health,

monthly intervals. The worker may

Epidemiological

Studies

Laboratory, 1974.

return to work with organophosphates


ACHE has returned to more than

Malathion).

Workers -Guidelines for Physicians.

All suspended cases should have

and/or carbamates when the plasma

Medical

to

Namba T: Cholinesterase Inhibition by


Organophosphorus Compounds and

70% of the pre-employment level.


Department of Occupational Safety and Health (DOSH) Malaysia

112

Guidelines On Medical Surveillance

its Clinical Effects. Bull. WId Hlth Org.

Route of entry

1974: 44: 289-307.

Inhalation, ingestion, skin

Medved LI, Kagan Ju S: Pesticides,


organophosphorus.

In:

International

Office,

Labour

Safety,
1983:

Vo12: 1637-46.
5

World

2.0

OCCUPATIONS AT RISK OF
EXPOSURE

These substances look alike and can be


used for similar purposes.
Manufacture of tar, pitch, bitumen

Health

and creosote

Organisation:

Recommended Health-based Limits in

Water proofing of wood, making of

occupational exposed to pesticides -

roofing and insulating materials

Report of a WHO Study Group 1

Lining irrigation canals and reservoirs

Technical Report Series 677, Geneva,

Road surfacing

1982.

Lubricant for die moulds


Manufacture of dyestuff

American

Conference

Governmental

Industrial

Organophosphorus

of

Manufacture of paints

Hygienists:

Chemical feedstock for the production

Cholinesterase

of benzene, toluene, xylene, phenol

Inhibitors In: Documentation of the

Sealing agents e.g. in battery

Threshold Limit Values and Biological


Exposure Indices, 1999.
7

manufacture
3.0 TOXIC EFFECTS

Phoon WH, Magdalene Chan, Ho SF,

3.1

ACUTE EFFECTS

Dept of Industrial Health Guidelines

Skin burns

For Designated Factory Doctors-The

Eyes -blepharoconjunctivitis, keratitis

Factories

(Medical

Regulations

Dept

Examinations)
of

Community,

Occupational and Family medicine

3.2 CHRONIC EFFECTS


Skin & mucous membranes:

Irritation erythema, burning, itching,

National University of Singapore 1997.

followed by desquamation
(aggravated by sunlight)

32 & 33.

PITCH ,TAR, BITUMEN &


CREOSOTE

Pigmentation changes -

1.0 SYNONYMS : Coal tar pitch, black oil

hyperpigmentation (primarily

Physicochemical properties. Thick dark

forearms, wrists, hands, scrotum)

bituminous mixture: tarry odour


PEL 8hr TWA: 0

Follicular dermatitis (comedones,


acne, sebaceous cysts)

Department of Occupational Safety and Health (DOSH) Malaysia

113

Guidelines On Medical Surveillance

Benign neoplasms -coarsening and

Clinical examination and baseline data,

hardening (shagreen appearance),

with particular emphasis on the:


Skin (pre-cancerous lesions) and

kerato-acanthoma, tar warts or


papillomata (Tar warts may be premalignant)

lungs.
Creasote in urine (diagnostic test)

Malignant neoplasms -epithelioma


(usually after 20 years of exposure.
Common sites are head, neck,

4.2

PERIODIC MEDICAL

EXAMINATIONS
Regular skin examination, of the skin

scrotum and upper limbs)

annually ensures early detection of re-

Respiratory:

cancerous lesions and their treatment


before cancer can develop. But frequency

Irritation -congestion, pneumonitis

will

Squamous cell and/or oat cell


carcinoma (evidence still uncertain)
(Due to residues of coal tar distillation;

depend

on

5.0 WHERE

3-4-benzpyrene, 1,2,5,6-

FOLLOWING

dibenzanthracene)

DONE

Burning pain

Diarrhoea

may

be

present

in

may

heavy tar oils, soot, creosote oil and


oil

INDICATED,

6.0 INDICATIONS

substances : - pitch, coal tars, bitumen,


shale

and

TESTS

THE

MAY

BE

Skin biopsies

Carcinogenic products of carbonaceous


materials

levels

CXR

Gastrointestinal tract:

exposure

symptoms and signs.

and

its

distillation

and

fractionation products.

FOR

MEDICAL

REMOVAL PROTECTION
All cases with pre-malignant lesions
and definite or suspected
benign/malignant neoplasms of the
skin and lungs.
All cases recommended for MRP and
suspected cases of benign/malignant

In these complex mixtures, polycyclic

neoplasms related to tar, pitch, bitumen,

aromatic hydrocarbon are probably the

and creosote must be notified to the DG

actual carcinogens.

(DOSH).

4.0 MEDICAL SURVEILLANCE

6.0 FOLLOW-UP ACTION

PRGRAMME

Cases with evidence of abnormal clinical

Any occupational exposure to pitch, tar,

findings should be investigated with a view

bitumen and creosote.

to confirming the diagnosis.

4.1

PRE-PLACEMENT MEDICAL

6.1 ABNORMAL RESULTS

EXAMINATIONS

Repeat tests

Department of Occupational Safety and Health (DOSH) Malaysia

114

Guidelines On Medical Surveillance

3
6.2

Risk of Cancer from the use of Tar,

MEDICALLY REMOVED WORKERS

Bitumen in Road Works. Br J Ind M.ed,

& RETURN TO WORK

46:1,24-30, 1989. 6.14.3.

All medically removed workers


should have repeat investigations

Control of Substances Hazardous to

and relevant biochemical tests within

Health (COSHH) Regulations 11-

one month.

Health Surveillance- carbonaceous

The worker should not return to work

agents associated with skin cancers in

until the signs and symptoms and

HSF, 1989.

abnormal cytology/ biochemical


results have disappeared.
34. VINYL CHLORIDE MONOMER

Recommend the worker for return to


work when the

(VCM)

workplace hygiene

is safe and healthy and does not


place the worker at increased risk of
material impairment to health from
exposure to pitch, tar, bitumen &

1.0

PEL 8hr TWA: 1 ppm


Route of entry
Inhalation, skin

creosote.
7.0 PREVENTIVE MEASURES

2.0

EXPOSURE

aware of the dangers of the

(Production of polyvinyl chloride

substances they are handling

resins (workers who clean and

The employer should be

maintain the reactors are especially

encouraged to examine their skin

at risk)
Storage of VCM

lesions to the OHD.

Sampling and analysis of VCM

Appropriate signage

3.0 TOXIC EFFECTS

8.0 REFEERNCES
International Labour Office:
Encyclopaedia of Occupational Health
and Safety, Geneva, 3rd

3.1 ACUTE EFFECTS


Non-specific manifestations e.g.

edition, p

569-570, 198-200, 1983: 2147-2149.


2

OCCUPATIONS AT RISK OF

Workers at risk should be made

regularly and report any suspicious

SYNONYMS: Cholroethylene

headache, giddiness, disorientation.

consciousness.

International Agency for Research on


Cancer. Annual Report, World Health
Organisation, 1983: 39.

May progress to loss of

Lung irritation

Skin irritation

Department of Occupational Safety and Health (DOSH) Malaysia

115

Guidelines On Medical Surveillance

3.2

CHRONIC EFFECTS

4.2

PERIODIC MEDICAL

Raynaud' s phenomenon

EXAMINATIONS

Scleroderma-like lesions

Should cover the same areas as the pre-

Acro-osteolysis (especially of the


hands)
Liver and/or spleen fibrosis
Lung fibrosis
Pancytopenia

employment examination. An annual check


is appropriate.
4.3

WHERE INDICATED, THE


FOLLOWING TESTS MAY BE
DONE

Ultrasound
Liver Scan
Hand X -ray, to obtain baseline

Others

evidence of the state of the finger

bones

4.0

Angiosarcoma of the liver


MEDICAL SURVEILLANCE
PROGRAMME

Chest X-ray
Liver biopsy

Any occupational exposure to VCM.

Platelet count

4.1 PRE-PLACEMENT MEDICAL

Hepatitis screening

EXAMINATIONS

5.0 INDICATIONS MEDICAL REMOVAL

Clinical examination and baseline data with

PROTECTION

special attention to detecting pre-existing

All cases of definite or suspected VCM

abnormalities of the liver, spleen, skin and

diseases

circulation to extremities (hands.)

Workers with the following conditions: -

Liver function tests (Serum bilirubin,


alkaline phosphatase, alanine and
aspartate transaminases and
gamma-glutamyl transpeptidase
estimations)
Pulmonary Function Test

Persistent liver abnormalities (one or


more abnormal result in the liver
function test on at least 2 occasions
within a 1 month period).
Clinical evidence of liver disease e.g.
enlarged spleen, liver, spider naevi,
etc.

Worker should abstain from alcohol at least

All cases recommended for MRP and

1 week prior to undergoing the liver

suspected cases of VCM diseases must be

function tests.

notified to the DG (DOSH).


6.0 FOLLOW-UP ACTION

Department of Occupational Safety and Health (DOSH) Malaysia

116

Guidelines On Medical Surveillance

Repeat tests.

8.0
1.

6.1 ABNORMAL LFT RESULTS (one or

REFERENCES

International Labour Office:


Encyclopaedia of Occupational

more parameters)

Health and Safety Vol II, -2258, 1983:

Cases with abnormal liver function test

22:56.

results should be investigated to exclude


effects due to VCM. Please refer to the

2.

National Institute for Occupational

algorithm on page 3 (ALGORITHM FOR

Safety and Health: Technical

THE INVESTIGATION OF ABNORMAL

Information. A cross-sectional

LIVER FUNCTION TEST RESULTS).

epidemiological survey of vinyl

6.2

chloride workers. U.S. Department of

MEDICALLY REMOVED WORKER


&

Health, Education and Welfare1977:

RETURN TO WORK

No 77:177.

All suspended cases should be

3.

followed up.

Angiosarcoma in vinyl chloride

All removed cases should have repeat

workers -A systematic detection

liver function test at 3 monthly

program. Journal of the American

intervals.

Medical Association, 1974.

The worker may return to work with


VCM when the liver function results

4.

Smulevich, 'V .B, I. V Fedotova, V .S.

return to normal and he is clinically

Filatova: Increasing evidence of the

asymptomatic.

rise of cancer in workers exposed to

Recommend the worker for return to

vinyl chloride. Br J Ind Med,

work when the workplace hygiene is

1988,45:2; 93-7.

safe and healthy and does not place


the worker at increased risk of

5.

chloride disease. ZeIJltralblatt fur

exposure to vinyl chloride.

Arbeitsmedizin Arbeitsschutz and


Prophylaxe, 197:497- 104.

PREVENTIVE MEASURES
Improvement

in

workplace

work-process

hygiene

&

6.

Protective

equipment.

Roland S E Chong .An update on


Occupational Liver Disease. J Occup

Adequate

Medicine, Vol 2, No 2, July 1990:44-9.

ventilation
Personal

Reinl, W H. Weber: Status of


epidemiological research of vinyl

material impairment to health from

7.0

Makk, L; et al: Liver damage and

7.

Donald S Herip: Recommendations for

Chemical goggles

the investigation of abnormal hepatic

Workers should be advised to abstain

function in asymptomatic workers. Am

from alcohol

J Ind Medicine, 21: 1992: 331-9.

Appropriate signage
Department of Occupational Safety and Health (DOSH) Malaysia

117

Guidelines On Medical Surveillance

8.

Phoon WH, Magdalene Chan, Ho SF,


Dept of Industrial Health Guidelines
For Designated Factory Doctors-The
Factories

(Medical

Regulations

Dept

Examinations)
of

Community,

Occupational and Family medicine


National

University

of

Singapore

1997:36.1-361-5.
9.

Control of Substances Hazardous to


Health
Regulation

(COSHH)
11-Health

Regulations:
Surveillance-

Vinyl chloride in The Health and Safety


Factbook Health & safety Executive,
Professional Publishing Ltd London,
1989:1/9.

Department of Occupational Safety and Health (DOSH) Malaysia

118

Guidelines On Medical Surveillance

ALOGRITHM FOR THE INVESTIGATION OF ABNORMAL LIVER FUNCTION TEST


RESULTS
> 1 parameter raised and/or at least
1 parameter > 10% of the upper
limit of laboratory's range

Repeat abnormal
Parameter(s) in 2
weeks time

Parameter(s) <10%
upper limit

At least 1 parameter
> 10% upper limit

Temporary suspension
for 3 months. Repeat
abnormal parameters

No suspension
Fit for work

Parameter
< 10% upper

At least 1 parameter
> 10% upper limit

Hepatitis Screening Test


and ultra-sound test of
liver and spleen
Continue with
annual
examination

Normal

continue suspension
and review results
3 monthly

Abnormal ultra sound


and/or HbsAg positive

PERMANENT
SUSPENSION

LFT still abnormal


after 1 year of
suspension

Department of Occupational Safety and Health (DOSH) Malaysia

119

Guidelines On Medical Surveillance

35. NICKEL SULFIDE ROASTING,

Elemental/Metal

FUME AND DUST AS NICKEL

1.5

mg/m3

1.0 SYNONYMS: Nickel nitrate, nickel


sulphate

Insoluble compounds, as Ni

0.2

mg/m3

PEL 8hr TWA


Nickel
Soluble compounds, as Ni

0.1

mg/m3
Nickel subsulfide. as Ni

0.1

mg/m3

Route of Absorption
Inhalation
Dermal
2.0

Physicochemical properties

EXPOSURE

Nickel is a lustrous, grey white (silvery)

Alloys, catalyst

metal metal, which is ductile, malleable,

Ceramics

and with a fibrous structure

Electrolytic nickel-plating

Compounds crystals and powders

Mining and extraction of nickel

All forms are odourless


Manufacture

of

nickel

cadmium

Pustulation

and

usually clears in one week.

Fumes

highly

Anosmia

Some compounds are human nasal and


lung carcinogens (IARC 1)
Carcinoma of nasal sinuses and lung

3.1 ACUTE EFFECTS


irritating

to

after chronic exposure to dusts and

the

respiratory tract.
Metal fume fever
CHRONIC EFFECTS

Severe dermatitis and eczema via


sensitisation

body.

ulceration may occur. " Nickel itch"

3.0 TOXIC EFFECTS

3.2

of

batteries

Coin and kitchen utensil manufacture

parts

Welding
Pewter articles manufacture

OCCUPATIONS AT RISK OF

Sensitisation is permanent

fumes in the refining processes

Asthma

Skin senzitiser and irritant

4.0 MEDICAL SURVEILLANCE


PROGRAMME
Any work where workers are exposed to
levels of airborne levels which are liable to

"Nickel itch" upon repeated exposure.

be in excess of half the -in-air standard and

Pink papular erythema of webs of

or where there is significant risk of

fingers, which may spread to other

ingesting it.

Department of Occupational Safety and Health (DOSH) Malaysia

120

Guidelines On Medical Surveillance

4.1

PRE-PLACEMENT MEDICAL

Refer to urologist for abnormal cytology.

EXAMINATIONS
Clinical examination and baseline with

6.2 MEDICALLY REMOVED WORKER &


RETURN TO WORK

particular attention to:

All suspended cases should have

Skin- Patch test for nickel for nickel in

repeat

sensitisation

investigation

examinations

Nasal sinuses

urine

and

relevant

biochemical tests where indicated

Chest X-Ray

and should not return to work until the

Increased nickel in urine Health Safety

signs and symptoms and abnormal

Executive UK,

biochemical

Urine Nickel in the unexposed is 1-

results

have

disappeared.

10nmol/mmol creatinine.

Recommend the worker for return to

There is NO Biological Exposure

work when the workplace hygiene is

Index (BEI) for Nickel

safe and healthy and does not place

Relative contraindications are individuals

the worker at increased risk of

with diseases of skin, sinuses and lung.

material impairment to health from

4.2

exposure to chemical hazardous to

PERIODIC

MEDICAL

health.

EXAMINATIONS
6.3

As for pre-employment, periodic


examination for

All

Urine nickel.
5.0

TREATMENT
cases

of

poisoning

must

be

immediately removed from exposure


and referred for hospital treatment.

INDICATIONS FOR MEDICAL

Wash contaminated areas of body with

REMOVAL PROTECTION

soap and water.

All cases of definite or suspected


poisoning/ disease and excessive

Suggest the use of dimercaprol

absorption.
All cases recommended for suspension
and

suspected

7.0

cases of poisoning /

Improvement in work-process

excessive absorption must be notified to

Prompt attention to all cutaneous


wounds

the DG (DOSH).
6.0

FOLLOW-UP ACTIONS

6.1

ABNORMAL RESULTS

If abnormal urine cytology, symptoms

Workplace
ventilation

hygiene,

Adequate

Approved
Personal
Protective
equipment. Chemical goggles.

&

signs persist, a repeat test must be done


immediately.

PREVENTIVE MEASURES

9.0

Appropriate signage
REFERENCES

Department of Occupational Safety and Health (DOSH) Malaysia

121

Guidelines On Medical Surveillance

12. Olson KR Poisoning & Drug overdose,

15. Rom

MN

Environmental
nd

&

A Lang clinical manual, Prenctice-Hall

occupational medicine 2

Int, Inc 1999: 498t.

Brown & Co. Boston, Toronto, London

13. Plunkett E R Handbook of Industrial


toxicology, Industrial Health Services
Barberton, Ohio. 288 1987:287.
14. International

Labour

Edition Little

1992.
16. Information notices on Diagnosis of
occupational diseases Nickel and its

Office:

Encyclopaedia of Occupational Health

compounds

European Commission

1994:38.

and Safety, Geneva, 4th edition, 1998.

Department of Occupational Safety and Health (DOSH) Malaysia

122

Guidelines on Medical Surveillance

USECHH 1

OCCUPATIONAL MEDICAL SURVEILLANCE PROGRAMME


RECORD BOOK

Occupational Safety and Health


(Use and Standards of Exposure of Chemicals Hazardous to Health)
Regulations 2000

Department of Occupational Safety & Health


Ministry of Human Resources

This document is confidential. A copy must be kept by the


employee and one by Occupational Health Doctor. When a
change in the Occupational Health Doctor occurs this document
must be produced to the next Occupational Health Doctor.
It must be produced to the Occupational Health Doctor
whenever the employee comes for medical examination
Please write clearly

Department of Occupational Safety and Health (DOSH) Malaysia

Guidelines on Medical Surveillance


A. GENERAL INFORMATION
Name of worker
Address
District

State

Post-Code

Home Tel No.


IC No.

Age

years

SOSCO No.
Worksman's Compensation No.
Work Permit No.
Sex

Male
Female

Status

Ethnic

Malay
Chinese
Indian
Others (specify)

Single
Married

No. of child
No. of years married

Nationality

Malaysian Citiven
non Citiven (specify)

Next of kind to be contacted in case of emergency


Name
Relationship
Address
Tel. No.
Name Of Employer
Employer Address

Tel No.

Fax/e-mail

Name of officer at workplace to be contacted for further investigation


Position :

Tel. No.
Fax/e-mail

Department of Occupational Safety and Health (DOSH) Malaysia

years

Guidelines on Medical Surveillance


Please answer the following questions
Do you have any history of or suffering from the following conditions?
Smoker
Non smoker
Stopped smoking

No. of years smoked


No. of cigeratte/day

Medical condition
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Eye problem (including difficulty to see at night)


Fits or convulsion of any kind
Serious head injury
Giddiness/severe headache/migrane
Fainting attacks
Major brain surgery
Stroke with residual disabiity
Diabetes mellitus on insulin
Mental illness (stress)
Alcohol abuse in the last five years
Drug abuse in the last five years
Deformity or disability of the limbs/spine
Heart disease/Hypertension/Palpitation
Breathlessness/Haemoptysis/Chronic cough
Hearing problem
Chronic Kidney disease
Are you on any regular medication at present?
Do you have any other injury or illness not mentioned above?

If yes (specify)

Name of medicine

This is to certify that the above statement are true. I give consent to the OHD for Medical Examination
to communicate with the management regarding my work capability after discussion with me.
Witnesses by Doctor

Signature by :
Date:

(Name of Doctor)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

B. PAST MEDICAL HISTORY (to be filled by Doctor)


Y
N
System
If yes (specify)
Central Nervous System
Peripheral Nervous System
Cardiovascular System
Respiratory System
Gastrointestinal
Musculoskeletal
Endocrine/Metabolic
Genitourinary
Reproductive
H/o allergy
Previous Hospitalization
H/o previous occupational diseases/injuries
Amount compensation paid
Have any of your co-workers experienced Occ.
diseases/poison/injury
Other health problem or injuries

Deparment of Occupational Safety and Health (DOSH) Malaysia

Guidelines on Medical Surveillance


C. MENSTRUAL HISTORY (FEMALE ONLY)
Age of menarche

Outcome of pregnancy

Regular Menses
Irregular Menses

No. of abortions
No. of stillbirth
D. FAMILY HISTORY
Y
N

1
2
3
4

specify
specify

If yes (specify)

H/o Medical illeness


H/o alllergy
H/o Congential malformation
Other illness

E. OCCUPATIONAL HISTORY
Past
1
2
3
4
5

Present

Job titles and duties


Type/level of hazard
Duration of employment
have you received training for this job
other job-other than this job

F. PRESENT CHEMICAL HISTORY AND EXPOSURE


The Employer must present the Chemical Health Risk Assessment Report to the OHD who
will analyse it before conducting Medical Examination
Y
N
If yes, Explain
Are you trained to recognise the symptoms
1
and signs of disease & poisoning due to
chemical used in the work place?
2
Do you have symptoms of signs disease due to
hazardous chemical used?
3
When (date) did you have the symptoms?
4
Are the PPE used approved by DOSH?
(specify the name of the chemical)
5
Has exposure monitoring bbeen conducted
for chemicals for which the worker is exposed?
Personal exposure result:
8 hour time weighed
average
Maximum exposure limit
Workplace monitoring:

Department of Occupational Safety and Health (DOSH) Malaysia

Guidelines on Medical Surveillance

G. PHYSICAL EXAMINATION
1 Anthopometry :
Weight
Height
BMI

Kg
cm

* BM result

<20 - underweight
20-25 Ideal weight
25-30 Overweight
>30-Obesity

Blood Pressure
Pulse

2 General appearance
Eye
Vision
Field vision
Colour vision
Fundoscopy

Ear

Right

Right

Left

External canal
Ear drum
Air conduction
Bone conduction

Nose
Throat
Lymphatics

Nails
Vericose vein

Skin

3 Central Nervous system


Orientation to time,
place and person
Others

Cardio vascular system


Auscultation
DRNM
Others

5 Respiratory system
Chest expension
Air entry
Crepitations
Wheeze
Others

Gastrointestinal system
Liver
Spleen
Abdomen
Others

7 Genitourinary
Kidney
Bladder
Uterus
Others
8 Musculoskeletal
Lower Limbs

Upper Limbs
R

Power
Reflex
Sensation

Department of Occupational Safety and Health (DOSH) Malaysia

R
Power
Reflex
Sensation
Others

Guidelines on Medical Surveillance


H. INVESTIGATION TO BE DONE /DONE
BASELINE/PREPLACEMENT/PERIODIC/POST-EMPOYMENT
DATE:
Result

Investigation
Urine
FEME
Blood
Hb
BUSE
Renal profile
Liver function test
Others (specify)
Sputum for AFB
CXR
Lung function test
FVC
FEV1
FEV1/FVC
Audigram

Immunisation status
Other (specify)

The implication of the above results has been explained to me by the OHD

Signature of the employee

Date

Department of Occupational Safety and Health (DOSH) Malaysia

Guidelines on Medical Surveillance

USECHH 2
(USE AND STANDARD OF EXPOSURE OF CHEMICALS HAZARDOUS TO HEALTH)
REGULATIONS 2000

EMPLOYEE
MEDICAL RECORD BOOK

(Company Logo)

Name :

Date of Medical
Examination
11.2.2001

Result of Biological
Monitoring

Fitness to Work
(Fit, Further Tests Needed)

Blood lead Level 50


mg/dl

Department of Occupational Safety and Health (DOSH) Malaysia

Name of OHD,
DOSH Reg. No.
Dr.
JKKP IH 127/171-1( )

Guidelines on Medical Surveillance

USECHH 3
Occupational Safety and Health Act 1994
(Act 514)
Occupational Safety and Health (Use and Standard of Exposure of Chemicals
Hazardous to Health) Regulations 2000
CERTIFICATE OF FITNESS
Name of Person examined
NRIC/Passport No.

Date of Birth

Sex

Name & Address of Employee

Examination/Tests done and the results:


I hereby certify that I have examined the abovenamed person on
and that he is fit/not fit for work which may expose him to

Remarks (if any):

Signature & Date


Name of Occupational Health Doctor
(in BLOCK letters)
DOSH Reg. No. ________________________
_____________________________________
Address of Practice
Department of Occupational Safety and Health (DOSH) Malaysia

USECHH 4
Occupational Safety & Health Act 1994 (Act 514)
Use and Standards of Exposure of Chemicals Hazardous to Health Regulations 2000
SUMMARY REPORT FOR MEDICAL SURVEILLANCE
Name of Workplace: ______________________________________________________________
Address of Workplace: ____________________________________________________________
Company revenue / Annual income in RM____________________________________________
Work Unit where workers are in (please9): Production
maintenance
chemical /
heavy metals
laboratories
pesticides specify others: ____________________
Range
Date
Workplace exposure monitoring
Personal exposure monitoring
Control measures monitoring e.g.
LEV
Individual Chemical: ____________________________________________________________
(Use one USECHH4 form for one chemical only!)
Chemical listed under which Schedule under USECHH2000 Regulations: ____________________
Date of CHRA conducted (Put not done if CHRA is not done): ___________________________
Total number workers in that workplace: _____________________________________________
Total number of exposed workers: __________________________________________________
Types of test performed: _________________________________________________________
EXAMINATION(S) RESULTS
Test Performed
Clinical Features & Biological
Monitoring

Other test (To specify):


Blood/Spirometry/Urine etc

No. of workers examined


No. of workers with normal
results
No. of workers with
abnormal results
(Occupational caused)
No. of workers with
abnormal results (NonOccupational caused)
No. of workers
recommended for removal
Continue in separate sheet if required. Please include details of abnormal examination/test results in
USECHH 5ii form and Medical Removal Protection in USECHH 5i form.
I hereby declare that all particulars given in this report are accurate to the best of my knowledge.
Name of Occupational Health Doctor: ________________________________________________
OHD Registration No: _____________________________________________________________
Name of Practice & Address: _______________________________________________________
Duration/Experience as Medical Practitioner (in years): __________________________________
Tel No: ______________
HP no: _________________
Fax No: ___________________
Valid email address: ___________________________________
Date:

Signature:

Submit this form within 30 days of completion of medical surveillance to the Director General, Department of
Occupational Safety and Health, Level 2, 3 & 4, Block D3, Parcel D, 62530, Putrajaya. Download this form at
http://www.dosh.gov.my Please ensure all items in the form are completed. Incomplete forms will be returned.

USECHH 5i
Occupational Safety and Health Act 1994 (Act 514)
Use and Standard of Exposure of Chemicals Hazardous to Health Regulation 2000
MEDICAL REMOVAL PROTECTION
1. Name of Worker ____________________________________________
2. NRIC/Passport No.____________________________________________
3. Socso No. ________________ 4. Date of Birth _____________________ 5. Sex ____________
6. Name and Address of Workplace: ___________________________________________________
7. Date of starting employment: _____________ Duration of Employment (years):______________
8. Health Hazard Present (Use one form for one chemical): ________________________________
I certify that the above named person examined by me on (dd/mm/yy) ________________________
should not continue to work a as (designated) _____________________________in (place of work)
______________________ department/ section for ____________________months, subject to a
review on (dd/mm/yy) ___________________
In the mean time, he should be given alternative work in another department / section which does not
expose him to (name of individual chemical) _________________________________
The reasons for my recommendations are as follows (please9): Pregnancy Breast Feeding
Abnormal Result Toxicity based on History & Physical Examination specifies others:
______________________________________________________________________________

Name of OHD (in BLOCK LETTERS): _______________________________________________


OHD_DOSH Registration number: ______________________________________________
Practice Address: ______________________________________________________________
_____________________________________________________________________________
Email Address: ________________________________________________________________
H/P: ______________________ Tel: _____________________ Fax: _____________________

___________________
OHD Signature

___________________
Date

Note: This certificate should be completed in triplicate and the original copy forwarded to the Director General,
Department of Occupational Safety and Health , Level 2, 3 & 4, Block D3, Parcel D, Federal Government
Administrative Centre, 62530 Putrajaya and must include the actual results of the relevant examination/tests.
The quantitative results (e.g. blood lead) the exact figures and measurements units must be clearly stated. Also
include copy of qualitative results (eg Chest X-ray). Incomplete form will be returned.

USECHH 5ii

Details of workers with abnormal examination results


Sex
No

Employees
Name

NRIC/
Passport

Job
category/
Designation

Department/
Work area

Hazards
exposed

Lab tests
performed

Results

Laboratory
normal
range

Existing
control
measures

Recommendations
/ action taken eg
MRP, Referal to
specialist, follow
up, repeat test etc

Submit this form together with USECHH 4 form within 30 days of completion of the medical surveillance to The Director General, Department of Occupational Safety And Health, Level 2, 3, and 4,
Block D3, Parcel D, Pusat Pentadbiran Kerajaan Persekutuan 62530 Putrajaya. This form can be downloaded from http://www.dosh.gov.my Continue in separate sheet if required.